Healthcare Provider Details

I. General information

NPI: 1801248059
Provider Name (Legal Business Name): BRAD L ECKLOR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 PARKER ST
BOSCOBEL WI
53805-1648
US

IV. Provider business mailing address

100 VIKING ST
COON VALLEY WI
54623-8338
US

V. Phone/Fax

Practice location:
  • Phone: 608-375-4144
  • Fax:
Mailing address:
  • Phone: 608-498-0448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3796-23
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: