Provider Demographics
NPI:1265412365
Name:HAYSSEN, THERESA K (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:K
Last Name:HAYSSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17000 W NORTH AVE
Mailing Address - Street 2:STE 107W
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4423
Mailing Address - Country:US
Mailing Address - Phone:262-786-3722
Mailing Address - Fax:262-786-0116
Practice Address - Street 1:17000 W NORTH AVE
Practice Address - Street 2:STE 107W
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4423
Practice Address - Country:US
Practice Address - Phone:262-786-3722
Practice Address - Fax:262-786-0116
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39624208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG88215Medicare UPIN