Basic Information
| Provider Information | |||||||||
| NPI: | 1851473680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JROLF | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | L | ||||||||
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| OtherLastName: | JROLF | ||||||||
| OtherFirstName: | JOEL | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1700 W PARADISE DR | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959795 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13133 N PORT WASHINGTON RD STE G-18 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530972420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622435000 | ||||||||
| FaxNumber: | 2622435317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 10/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1415 | WI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363A00000X | 1415 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2028 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER |