Basic Information
| Provider Information | |||||||||
| NPI: | 1114328226 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | VITCH | ||||||||
| FirstName: | JESSE | ||||||||
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| Credential: | AA | ||||||||
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| Mailing Information | |||||||||
| Address1: | W180N8085 TOWN HALL RD | ||||||||
| Address2: | DEPARTMENT OF ANESTHESIOLOGY | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622575100 | ||||||||
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| Practice Location | |||||||||
| Address1: | W180N8085 TOWN HALL RD | ||||||||
| Address2: | DEPARTMENT OF ANESTHESIOLOGY | ||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622575100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2014 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 88 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1114328226 | 05 | WI | MEDICAID |