Basic Information
| Provider Information | |||||||||
| NPI: | 1720750599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAU | ||||||||
| FirstName: | JILL | ||||||||
| MiddleName: | JANINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2031 N 49TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532081737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147596242 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19333 W NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530454132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627852000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2021 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 12004 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 196260-30 | WI | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 00000 | 01 | WI | N/A | OTHER |