MEDICARE: KIRSTEN J ANTONNEAU PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	1981	WI
2	363A00000X	Physician Assistant	1981-23	WI

General Provider Information

NPI Number	:	1467526400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN J ANTONNEAU PAC

Provider Business Mailing Address
First Line	:	1515 S GREENBAY RD
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53406-4409
Country	:	US
Telephone Number	:	262-632-1867
Fax Number	:	262-632-2656

Provider Business Practice Location Address
First Line	:	1300 S GREEN BAY RD STE 100
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-4469
Country	:	US
Telephone Number	:	262-619-4191
Fax Number	:	262-634-5185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	09/10/2021

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Directions to “ KIRSTEN J ANTONNEAU PAC” Practice Location

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