Healthcare Provider Details

I. General information

NPI: 1255588364
Provider Name (Legal Business Name): BRITTANY L PORTER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRITTANY L BRONSON PAC

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 11/17/2024
Certification Date: 11/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 MCHENRY ST
BURLINGTON WI
53105-1828
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-767-6100
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2308-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: