Provider Demographics
NPI:1063408334
Name:KUMAR, VASAVI (PA)
Entity type:Individual
Prefix:
First Name:VASAVI
Middle Name:
Last Name:KUMAR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VASAVI
Other - Middle Name:
Other - Last Name:REDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1111 DELAFIELD ST
Mailing Address - Street 2:STE 209
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3403
Mailing Address - Country:US
Mailing Address - Phone:262-542-0444
Mailing Address - Fax:262-542-8214
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:STE 209
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-542-0444
Practice Address - Fax:262-542-8214
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1000-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063408334Medicaid
WI682700017OtherMEDICARE ID
WI1063408334Medicaid