Provider Demographics
NPI:1639121312
Name:PESKE, CHRISTOPHER G (PA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:G
Last Name:PESKE
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 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-1686
Mailing Address - Fax:414-266-1525
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-1686
Practice Address - Fax:414-266-1525
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI592363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
001856578YOtherHUMANA
WI42926600Medicaid
001856578YOtherHUMANA
0005S73601Medicare ID - Type Unspecified
WI42926600Medicaid
P27184Medicare UPIN