MEDICARE: JULIE A VAJDA 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	1022023	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	:	1780677294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIE A VAJDA PAC

Provider Business Mailing Address
First Line	:	420 E DIVISION ST
Second Line	:
City	:	FOND DU LAC
State	:	WI
Zip	:	54935-4560
Country	:	US
Telephone Number	:	920-926-8340
Fax Number	:	920-926-8370

Provider Business Practice Location Address
First Line	:	430 E DIVISION ST
Second Line	:
City	:	FOND DU LAC
State	:	WI
Zip	:	54935-4560
Country	:	US
Telephone Number	:	920-929-2300
Fax Number	:

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	03/16/2016

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