Provider Demographics
NPI:1376679092
Name:DUDAS, KRISTEN L (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:L
Last Name:DUDAS
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 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:414-771-6780
Mailing Address - Fax:414-238-2424
Practice Address - Street 1:2885 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4404
Practice Address - Country:US
Practice Address - Phone:414-771-6780
Practice Address - Fax:414-238-2424
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41932600Medicaid
WI017100238Medicare PIN