Basic Information
| Provider Information | |||||||||
| NPI: | 1912221102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALECEK | ||||||||
| FirstName: | ERIN | ||||||||
| MiddleName: | CATHLEEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531472655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622454990 | ||||||||
| FaxNumber: | 2622452248 | ||||||||
| Practice Location | |||||||||
| Address1: | N2950 STATE ROAD 67 | ||||||||
| Address2: | |||||||||
| City: | LAKE GENEVA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531472655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622454990 | ||||||||
| FaxNumber: | 2622452248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2010 | ||||||||
| LastUpdateDate: | 05/17/2016 | ||||||||
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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 | 363A00000X | 085.004554 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3021-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PALECERI | 01 | WI | MERCYCARE INSURANCE | OTHER | 1912221102 | 05 | WI | MEDICAID |