Healthcare Provider Details

I. General information

NPI: 1447745021
Provider Name (Legal Business Name): CHLOE BEA FAGA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHLOE BEA VANDERWEELE PA-C

II. Dates (important events)

Enumeration Date: 06/26/2018
Last Update Date: 04/04/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S PARK ST
MADISON WI
53715-1830
US

IV. Provider business mailing address

2108 CENTER ST
CROSS PLAINS WI
53528-9621
US

V. Phone/Fax

Practice location:
  • Phone: 608-251-6100
  • Fax:
Mailing address:
  • Phone: 920-946-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: