Provider Demographics
NPI:1457372021
Name:KEHL, ELIZABETH A (PA)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:KEHL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:HEINRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1111 DELAFIELD ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3403
Mailing Address - Country:US
Mailing Address - Phone:262-542-0444
Mailing Address - Fax:262-542-8214
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 209
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3403
Practice Address - Country:US
Practice Address - Phone:262-542-0444
Practice Address - Fax:262-542-8214
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42887600Medicaid
WI001468270OtherMEDICARE ID
WI42887600Medicaid