Provider Demographics
NPI:1396781688
Name:ROBILLARD, DANIEL R (PA)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:ROBILLARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3238 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4535
Mailing Address - Country:US
Mailing Address - Phone:414-643-4430
Mailing Address - Fax:414-643-4693
Practice Address - Street 1:3238 S 16TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4535
Practice Address - Country:US
Practice Address - Phone:414-643-4430
Practice Address - Fax:414-643-4693
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42908700Medicaid
WI42908700Medicaid
WIS52496Medicare UPIN