Provider Demographics
NPI:1245203207
Name:SPONAGLE, CHRISTINE A (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:A
Last Name:SPONAGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 DELAFIELD ST
Mailing Address - Street 2:SUITE311
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3417
Mailing Address - Country:US
Mailing Address - Phone:262-544-4411
Mailing Address - Fax:262-650-3856
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE311
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-544-4411
Practice Address - Fax:262-650-3856
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43931020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34499700Medicaid
WII05958Medicare UPIN
WI34499700Medicaid