Provider Demographics
NPI:1215350921
Name:DEVRIES, ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:DEVRIES
Suffix:
Gender:F
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 1:2741 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3833
Mailing Address - Country:US
Mailing Address - Phone:715-732-1392
Mailing Address - Fax:
Practice Address - Street 1:2741 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3833
Practice Address - Country:US
Practice Address - Phone:715-732-1392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-31
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3233-23363A00000X
MI5601006915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN41200027Medicare Oscar/Certification
WI000040160Medicare Oscar/Certification
WIK400118395Medicare Oscar/Certification