Provider Demographics
NPI:1154635860
Name:LAVENHAGEN, KRISTIN M (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:LAVENHAGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 15TH AVENUE
Mailing Address - Street 2:LAKESHORE MEDICAL CLINIC
Mailing Address - City:SOUTH MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53172-1160
Mailing Address - Country:US
Mailing Address - Phone:414-768-5430
Mailing Address - Fax:414-762-4225
Practice Address - Street 1:331 E PUETZ RD
Practice Address - Street 2:LAKESHORE MEDICAL CLINIC
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-3253
Practice Address - Country:US
Practice Address - Phone:414-570-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2636-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2636-23OtherWISCONSIN LICENSE