Provider Demographics
NPI:1114394293
Name:KOLL, AMBER R (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:AMBER
Middle Name:R
Last Name:KOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:RAE
Other - Last Name:BURTARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-5312
Practice Address - Country:US
Practice Address - Phone:262-338-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3662-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100048002Medicaid