Provider Demographics
NPI:1114914744
Name:DEGENHARDT, GLORIA (PA)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:DEGENHARDT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:238 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:CASHTON
Mailing Address - State:WI
Mailing Address - Zip Code:54619-2002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W NORTH ST.
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:WI
Practice Address - Zip Code:54648-0225
Practice Address - Country:US
Practice Address - Phone:608-654-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant