Healthcare Provider Details

I. General information

NPI: 1831199439
Provider Name (Legal Business Name): CRAIG QUANDT-WALLE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N MEADE ST
APPLETON WI
54911-3454
US

IV. Provider business mailing address

PO BOX 88215
MILWAUKEE WI
53288-0001
US

V. Phone/Fax

Practice location:
  • Phone: 800-968-6866
  • Fax:
Mailing address:
  • Phone: 800-968-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1346023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: