Provider Demographics
NPI:1386290872
Name:LAQUERRE, MARY R (AA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:LAQUERRE
Suffix:
Gender:F
Credentials:AA
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Mailing Address - Street 1:225 S EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4257
Mailing Address - Country:US
Mailing Address - Phone:262-787-4050
Mailing Address - Fax:262-439-7683
Practice Address - Street 1:2323 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-291-1000
Practice Address - Fax:414-291-1113
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WIPENDING367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant