Healthcare Provider Details

I. General information

NPI: 1992717615
Provider Name (Legal Business Name): PAUL A HURST PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 W MAIN AVE
DE PERE WI
54115-9366
US

IV. Provider business mailing address

1385 W MAIN AVE
DE PERE WI
54115-9366
US

V. Phone/Fax

Practice location:
  • Phone: 920-433-9400
  • Fax: 920-455-9409
Mailing address:
  • Phone: 920-433-9400
  • Fax: 920-455-9409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1395
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: