Provider Demographics
NPI:1952562761
Name:BRACKMAN, ANDREA J (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:BRACKMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:J
Other - Last Name:SIROTAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2549 N LAKE DR
Mailing Address - Street 2:APT. 5
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-3816
Mailing Address - Country:US
Mailing Address - Phone:414-232-6878
Mailing Address - Fax:630-734-1560
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7884
Practice Address - Country:US
Practice Address - Phone:262-697-7000
Practice Address - Fax:630-734-1560
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI003832395Medicare PIN
WI65240044Medicare PIN