Provider Demographics
NPI:1346215241
Name:EBERDT, DAVID J (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:EBERDT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-1464
Mailing Address - Country:US
Mailing Address - Phone:608-592-3296
Mailing Address - Fax:
Practice Address - Street 1:160 VALLEY DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:WI
Practice Address - Zip Code:53555-1464
Practice Address - Country:US
Practice Address - Phone:608-592-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI424363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42911700Medicaid
R97691Medicare UPIN
001313018Medicare PIN
000357065Medicare PIN
000757120Medicare PIN
000815430Medicare PIN