Basic Information
| Provider Information | |||||||||
| NPI: | 1710252408 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITCZAK | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 N RIVERCENTER DR | ||||||||
| Address2: | SUITE #206 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532123981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142725623 | ||||||||
| FaxNumber: | 4142725617 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 N RIVERCENTER DR | ||||||||
| Address2: | SUITE #206 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532123981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142725623 | ||||||||
| FaxNumber: | 4142725617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2012 | ||||||||
| LastUpdateDate: | 03/14/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 4766-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.