Provider Demographics
NPI:1265628507
Name:VAN EGEREN, COLLEEN M (PA)
Entity Type:Individual
Prefix:MRS
First Name:COLLEEN
Middle Name:M
Last Name:VAN EGEREN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2700 E ENTERPRISE AVE
Mailing Address - Street 2:STE A
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7656
Mailing Address - Country:US
Mailing Address - Phone:920-406-9803
Mailing Address - Fax:
Practice Address - Street 1:715 SUPERIOR RD
Practice Address - Street 2:SUITE 120
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-7594
Practice Address - Country:US
Practice Address - Phone:920-406-9803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2178-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMV1636589OtherDEA CERTIFICATE