Healthcare Provider Details

I. General information

NPI: 1902433477
Provider Name (Legal Business Name): CHRISTINA NAGLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 THEDA CLARK MEDICAL PLZ
NEENAH WI
54956-2721
US

IV. Provider business mailing address

3101 WHITING AVE APT C4
STEVENS POINT WI
54481-5133
US

V. Phone/Fax

Practice location:
  • Phone: 920-358-1223
  • Fax: 920-358-1224
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5241
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: