Provider Demographics
NPI:1083814305
Name:LUIKART, KRISTEN MARY (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARY
Last Name:LUIKART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MARY
Other - Last Name:HALVORSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2021 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:ALLOUEZ
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2257
Mailing Address - Country:US
Mailing Address - Phone:920-965-0345
Mailing Address - Fax:
Practice Address - Street 1:2021 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:ALLOUEZ
Practice Address - State:WI
Practice Address - Zip Code:54301-2257
Practice Address - Country:US
Practice Address - Phone:920-965-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3113-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00468513OtherRAILROAD MEDICARE
MN748440000Medicaid
MN748440000Medicaid