Provider Demographics
NPI:1275594103
Name:KLINCK, MEGHAN VICTORIA (PA C)
Entity Type:Individual
Prefix:MRS
First Name:MEGHAN
Middle Name:VICTORIA
Last Name:KLINCK
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 1:17000 W BLUEMOUND RD STE C
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5951
Mailing Address - Country:US
Mailing Address - Phone:262-240-9640
Mailing Address - Fax:262-293-9659
Practice Address - Street 1:17000 W BLUEMOUND RD STE C
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5951
Practice Address - Country:US
Practice Address - Phone:262-240-9640
Practice Address - Fax:262-293-9659
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1519363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41964700Medicaid
WI41964700Medicaid
WI68010Medicare ID - Type Unspecified