Provider Demographics
NPI:1770018756
Name:SUCHOCKI, GINA M
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:SUCHOCKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:715-854-3940
Mailing Address - Fax:715-854-3941
Practice Address - Street 1:112 N US HIGHWAY 141
Practice Address - Street 2:
Practice Address - City:CRIVITZ
Practice Address - State:WI
Practice Address - Zip Code:54114-1708
Practice Address - Country:US
Practice Address - Phone:715-854-3940
Practice Address - Fax:715-854-3941
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7658-33363LF0000X
WI7658363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100067621Medicaid
WI473548414OtherTAX ID FOR AURORA BAY AREA MEDICAL GROUP