Provider Demographics
NPI:1154844488
Name:ANDERSON, KORTNEY L (PA-C)
Entity Type:Individual
Prefix:
First Name:KORTNEY
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KORTNEY
Other - Middle Name:
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:608-252-8268
Practice Address - Street 1:7102 MINERAL POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1706
Practice Address - Country:US
Practice Address - Phone:608-828-7603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4360-23363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1154844488Medicaid