Provider Demographics
NPI:1215248166
Name:BECKER, SUSAN R (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:BECKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:BOEBEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:999 N 92ND STREET
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-266-6550
Mailing Address - Fax:414-266-6579
Practice Address - Street 1:999 N 92ND STREET
Practice Address - Street 2:SUITE 320
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-266-6550
Practice Address - Fax:414-266-6579
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1215248166Medicaid
WI1215248166Medicaid