Provider Demographics
NPI:1700809928
Name:MENEFEE, ELLEN (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:MENEFEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:KINCAID
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300/ATTN. KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:788 N JEFFERSON ST
Practice Address - Street 2:SUITE 401
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3718
Practice Address - Country:US
Practice Address - Phone:414-226-4020
Practice Address - Fax:414-225-2929
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1700809928Medicaid
WI736450060Medicare PIN