1881661577 NPI number — KALYN R. HAFEMANN PA-C

Table of content: (NPI 1013080589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881661577 NPI number — KALYN R. HAFEMANN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAFEMANN
Provider First Name:
KALYN
Provider Middle Name:
R.
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:
MOE
Provider Other First Name:
KALYN
Provider Other Middle Name:
R.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881661577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
788 N. JEFFERSON STREET,
Provider Second Line Business Mailing Address:
SUITE 300/ATTN: KAAREN BUTZEN
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53202-3710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-272-8950
Provider Business Mailing Address Fax Number:
414-272-0859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
788 N. JEFFERSON STREET
Provider Second Line Business Practice Location Address:
SUITE 401
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53202-3710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-226-4020
Provider Business Practice Location Address Fax Number:
414-225-2929
Provider Enumeration Date:
03/02/2006

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: 363A00000X , with the licence number:  1288 , 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: 1881661577 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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