Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 2388 | WI |
NPI | 1003846171 |
---|---|
Provider Name | Roxanne Phelps |
First Address | Milwaukee, WI 53209-2042 |
Second Address | Menomonee Falls, WI 53051-2810 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/07/2006 |
Last Update Date | 30/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38580100 | (05) | WI |
P00450901 | RR MEDICARE (01) | WI |
U19650 | (02) | WI |