Provider Demographics
NPI:1144272600
Name:WICHGERS, TERRI A (PA)
Entity type:Individual
Prefix:MS
First Name:TERRI
Middle Name:A
Last Name:WICHGERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2893 S 128TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-4029
Mailing Address - Country:US
Mailing Address - Phone:920-574-8670
Mailing Address - Fax:
Practice Address - Street 1:2893 S 128TH ST
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4029
Practice Address - Country:US
Practice Address - Phone:920-574-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42865900Medicaid
Q59636Medicare UPIN
WI42865900Medicaid