Provider Demographics
NPI:1417999269
Name:KUPHAL, DAVID M (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:KUPHAL
Suffix:
Gender:M
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-683-5278
Mailing Address - Fax:920-686-9674
Practice Address - Street 1:188 ROCKWOOD LN
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1983
Practice Address - Country:US
Practice Address - Phone:920-725-4100
Practice Address - Fax:920-725-5528
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1774-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1774-023OtherSTATE LICENSE
WI1774-023OtherSTATE LICENSE
WI382000018OtherMEDICARE PTAN
WIMK0572126OtherDEA