Provider Demographics
NPI:1043312937
Name:ISHERWOOD, KELLY A (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:ISHERWOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 N LAKE DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53211-4528
Mailing Address - Country:US
Mailing Address - Phone:414-298-7280
Mailing Address - Fax:414-298-7281
Practice Address - Street 1:2350 N LAKE DR
Practice Address - Street 2:SUITE 206
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7280
Practice Address - Fax:414-298-7281
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1675-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42866700OtherNETWORK HEALTH - T19
WI42866700Medicaid
42866700OtherMANAGED HEALTH SERVICES
WI42866700OtherWPS GAMP
WI42866700OtherUHC-T19
WI42866700OtherHIRSP
Q08395Medicare UPIN
000060295-0002Medicare ID - Type UnspecifiedSHEBOY & OSH COUNTIES
WI42866700OtherUHC-T19
42866700OtherMANAGED HEALTH SERVICES
WI42866700Medicaid
000052075-0002Medicare ID - Type UnspecifiedRACINE COUNTY
P00794219Medicare PIN
WI1634-003Medicare PIN