Provider Demographics
NPI:1861903130
Name:BUKOWSKI, JOHN ELMER (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ELMER
Last Name:BUKOWSKI
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2000 E LAYTON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-6067
Mailing Address - Country:US
Mailing Address - Phone:414-747-8856
Mailing Address - Fax:262-303-5006
Practice Address - Street 1:2000 E LAYTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235
Practice Address - Country:US
Practice Address - Phone:414-747-8856
Practice Address - Fax:262-303-5006
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2021-11-29
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1861903130Medicaid