Provider Demographics
NPI:1467593079
Name:HERCZOG, DEBORAH A (MSN, ANP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:HERCZOG
Suffix:
Gender:F
Credentials:MSN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N2994 PEBBLE VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:STODDARD
Mailing Address - State:WI
Mailing Address - Zip Code:54658-9018
Mailing Address - Country:US
Mailing Address - Phone:608-787-0172
Mailing Address - Fax:
Practice Address - Street 1:328 FRONT ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4023
Practice Address - Country:US
Practice Address - Phone:608-783-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX531773363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health