Healthcare Provider Details

I. General information

NPI: 1760963862
Provider Name (Legal Business Name): ELIZABETH BOHRER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 KEPLER DR
GREEN BAY WI
54311-8306
US

IV. Provider business mailing address

1035 KEPLER DR
GREEN BAY WI
54311-8320
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-5555
  • Fax: 920-288-5550
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-405-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4537
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: