1699737387 NPI number — DEBORAH E DEGNAN PA-C

Table of content: DEBORAH E DEGNAN PA-C (NPI 1699737387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699737387 NPI number — DEBORAH E DEGNAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEGNAN
Provider First Name:
DEBORAH
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699737387
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 249
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT ATKINSON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53538-0249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-568-5411
Provider Business Mailing Address Fax Number:
920-568-4004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1504 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT ATKINSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53538-3100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-563-7888
Provider Business Practice Location Address Fax Number:
920-563-7741
Provider Enumeration Date:
04/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  1269-023 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 1269 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41933000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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