Provider Demographics
NPI:1902955933
Name:PTAK, RENATA B (PA-C)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:B
Last Name:PTAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RENATA
Other - Middle Name:B
Other - Last Name:PTAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:2501 W SILVER SPRING DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4217
Mailing Address - Country:US
Mailing Address - Phone:414-461-9250
Mailing Address - Fax:414-461-3553
Practice Address - Street 1:2501 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4217
Practice Address - Country:US
Practice Address - Phone:414-461-9250
Practice Address - Fax:414-461-3553
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1779-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant