Healthcare Provider Details

I. General information

NPI: 1558882555
Provider Name (Legal Business Name): KRISTEN JEANNE BROCKDORF PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN JEANNE BAUGNET

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 E CAPITOL DR
APPLETON WI
54911-8735
US

IV. Provider business mailing address

2500 E CAPITOL DR
APPLETON WI
54911-8735
US

V. Phone/Fax

Practice location:
  • Phone: 920-364-3600
  • Fax: 920-364-3900
Mailing address:
  • Phone: 920-364-3600
  • Fax: 920-364-3900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number249004
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number404123
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number404123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: