Provider Demographics
NPI:1073920708
Name:BURG, KRISTEN N
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:N
Last Name:BURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-0249
Mailing Address - Country:US
Mailing Address - Phone:920-568-5411
Mailing Address - Fax:920-568-4004
Practice Address - Street 1:611 SHERMAN AVE E
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1960
Practice Address - Country:US
Practice Address - Phone:920-568-5000
Practice Address - Fax:920-568-4004
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI157243367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered