Basic Information
| Provider Information | |||||||||
| NPI: | 1952562761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRACKMAN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIROTAK | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | J. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2549 N LAKE DR | ||||||||
| Address2: | APT. 5 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532113816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142326878 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Practice Location | |||||||||
| Address1: | 10400 75TH ST | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531427884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2626977000 | ||||||||
| FaxNumber: | 6307341560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 01/19/2012 | ||||||||
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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 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.