Basic Information
| Provider Information | |||||||||
| NPI: | 1992339592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STATZA | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | SUE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1640 RIVERS BND APT 311 | ||||||||
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| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622255425 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1155 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4149555990 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 12/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | 5665-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.