Provider Demographics
NPI:1235127903
Name:CARACCI, KOBI S (PA-C)
Entity Type:Individual
Prefix:
First Name:KOBI
Middle Name:S
Last Name:CARACCI
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:PO BOX 117
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-0117
Mailing Address - Country:US
Mailing Address - Phone:920-739-5642
Mailing Address - Fax:920-968-0259
Practice Address - Street 1:900 E GRANT ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3487
Practice Address - Country:US
Practice Address - Phone:920-738-6340
Practice Address - Fax:920-738-6435
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R23397Medicare UPIN