Healthcare Provider Details

I. General information

NPI: 1003259649
Provider Name (Legal Business Name): KRYSTINA MARIE PISCHKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2013
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 S COMMERCIAL ST
NEENAH WI
54956-4802
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 920-729-6088
  • Fax: 920-729-6484
Mailing address:
  • Phone: 920-830-5900
  • Fax: 920-738-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number63282
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: