Basic Information
| Provider Information | |||||||||
| NPI: | 1851360218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WACHHOLZ | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8007 EXCELSIOR DR | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295247 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Practice Location | |||||||||
| Address1: | 451 JUNCTION RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082630150 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 57828 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 39900700 | 05 | WI | MEDICAID |