Basic Information
| Provider Information | |||||||||
| NPI: | 1174939409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WITT | ||||||||
| FirstName: | LORRAINE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 788 N JEFFERSON ST | ||||||||
| Address2: | SUITE 300/ATTN. KAAREN BUTZEN | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532023718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142728950 | ||||||||
| FaxNumber: | 4142252929 | ||||||||
| Practice Location | |||||||||
| Address1: | 13133 N PORT WASHINGTON RD STE G16 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530972423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622432500 | ||||||||
| FaxNumber: | 2622435395 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3189-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1174939409 | 05 | WI | MEDICAID |