Provider Demographics
NPI:1174789283
Name:SHAH, BREANNE K PACHECO (MD, MPH)
Entity type:Individual
Prefix:
First Name:BREANNE
Middle Name:K PACHECO
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:BREANNE
Other - Middle Name:KERRY
Other - Last Name:PACHECO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MPH
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-2625
Mailing Address - Fax:414-266-2635
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-2625
Practice Address - Fax:414-266-2635
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125055168208000000X
WI55838208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1174789283Medicaid
WI68086 0989Medicare PIN
WI73601 2222Medicare PIN