Provider Demographics
NPI:1538721451
Name:DEPPONG, ALYSSA S (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:S
Last Name:DEPPONG
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12500 AURORA DR
Mailing Address - Street 2:
Mailing Address - City:PLEASANT PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53158-1227
Mailing Address - Country:US
Mailing Address - Phone:262-857-5000
Mailing Address - Fax:
Practice Address - Street 1:12500 AURORA DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1227
Practice Address - Country:US
Practice Address - Phone:262-857-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4736-23207RG0100X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100091500Medicaid