Basic Information
| Provider Information | |||||||||
| NPI: | 1518930130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAJAFSKY | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | N17 W24100 RIVERWOOD DRIVE | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531881177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629284100 | ||||||||
| FaxNumber: | 2629285835 | ||||||||
| Practice Location | |||||||||
| Address1: | 2130 BIG BEND ROAD | ||||||||
| Address2: | PROHEALTH CARE MEDICAL ASSOCIATES, INC | ||||||||
| City: | WAUKESHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2629287555 | ||||||||
| FaxNumber: | 2625137575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 11/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1803 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43997200 | 05 | WI | MEDICAID |