Healthcare Provider Details

I. General information

NPI: 1356392237
Provider Name (Legal Business Name): AUDRA L YENTZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 TOWER DR
SUN PRAIRIE WI
53590-1239
US

IV. Provider business mailing address

10 TOWER DR
SUN PRAIRIE WI
53590-1239
US

V. Phone/Fax

Practice location:
  • Phone: 608-825-3008
  • Fax: 608-825-3786
Mailing address:
  • Phone: 608-825-3008
  • Fax: 608-825-3786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number652-023
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number652-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: