Provider Demographics
NPI:1467526400
Name:ANTONNEAU, KIRSTEN J (PAC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:J
Last Name:ANTONNEAU
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 S GREENBAY RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4409
Mailing Address - Country:US
Mailing Address - Phone:262-632-1867
Mailing Address - Fax:262-632-2656
Practice Address - Street 1:1300 S GREEN BAY RD STE 100
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4469
Practice Address - Country:US
Practice Address - Phone:262-619-4191
Practice Address - Fax:262-634-5185
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1981363AM0700X
WI1981-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical