Healthcare Provider Details

I. General information

NPI: 1417999269
Provider Name (Legal Business Name): DAVID M KUPHAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 ROCKWOOD LN
NEENAH WI
54956-1983
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 920-725-4100
  • Fax: 920-725-5528
Mailing address:
  • Phone: 920-683-5278
  • Fax: 920-686-9674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1774-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: