Provider Demographics
NPI:1356867006
Name:FELLAND, KYOKO (PA)
Entity Type:Individual
Prefix:
First Name:KYOKO
Middle Name:
Last Name:FELLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KYOKO
Other - Middle Name:
Other - Last Name:BALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1265 JOHN Q HAMMONS DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-1921
Mailing Address - Country:US
Mailing Address - Phone:608-828-4853
Mailing Address - Fax:
Practice Address - Street 1:675 W WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2637
Practice Address - Country:US
Practice Address - Phone:608-257-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4139-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant