MEDICARE: ASHELEY ROBYN GOERGEN 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	363A00000X	Physician Assistant	1881-23	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720034267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHELEY ROBYN GOERGEN PAC

Provider Business Mailing Address
First Line	:	6308 8TH AVENUE
Second Line	:	ATTN: MEDICAL STAFF OFFICE
City	:	KENOSHA
State	:	WI
Zip	:	53143
Country	:	US
Telephone Number	:	262-656-2218
Fax Number	:	262-653-5850

Provider Business Practice Location Address
First Line	:	9555 76TH ST STE 1200
Second Line	:
City	:	PLEASANT PRAIRIE
State	:	WI
Zip	:	53158-1984
Country	:	US
Telephone Number	:	262-671-7300
Fax Number	:	262-671-7315

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	05/25/2017

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Directions to “ ASHELEY ROBYN GOERGEN PAC” Practice Location

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