Provider Demographics
NPI:1154355584
Name:RHODES, GERALD L (PA-C)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:L
Last Name:RHODES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4815
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:111 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4815
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI300-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00302103OtherMEDICARE RAILROAD
WI42904700Medicaid
WI0060-07660Medicare ID - Type Unspecified
WI42904700Medicaid
S33843Medicare UPIN
WI0034-45034Medicare ID - Type Unspecified