Healthcare Provider Details

I. General information

NPI: 1639663503
Provider Name (Legal Business Name): KAITLYN SOUKUP SCHNEIDER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 RANDOLPH CT
MANITOWOC WI
54220-8345
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 920-683-5278
  • Fax: 920-482-0359
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4386
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100078943
Identifier TypeMEDICAID
Identifier StateWI
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: