Healthcare Provider Details

I. General information

NPI: 1548566391
Provider Name (Legal Business Name): AGNES M KANIKULA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 MAIN ST
PLAIN WI
53577-9668
US

IV. Provider business mailing address

825 MAIN ST
PLAIN WI
53577-9668
US

V. Phone/Fax

Practice location:
  • Phone: 608-546-4211
  • Fax: 608-546-2440
Mailing address:
  • Phone: 608-546-4211
  • Fax: 608-546-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2616-23
License Number StateWI

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: