Healthcare Provider Details

I. General information

NPI: 1780679381
Provider Name (Legal Business Name): CARRIE BACH PA-C, MPAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7102 MINERAL POINT RD
MADISON WI
53717-1706
US

IV. Provider business mailing address

7974 UW HEALTH CT
MIDDLETON WI
53562-5531
US

V. Phone/Fax

Practice location:
  • Phone: 608-828-7603
  • Fax: 608-828-7644
Mailing address:
  • Phone: 608-829-5485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2104
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: