Provider Demographics
NPI:1467902874
Name:FORMANKIEWICZ, SARA (PA-C)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:FORMANKIEWICZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:BUSSKOHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 N DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:REEDSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53959-1049
Mailing Address - Country:US
Mailing Address - Phone:608-768-3900
Mailing Address - Fax:
Practice Address - Street 1:2000 N DEWEY AVE
Practice Address - Street 2:
Practice Address - City:REEDSBURG
Practice Address - State:WI
Practice Address - Zip Code:53959-1049
Practice Address - Country:US
Practice Address - Phone:608-768-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3930363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant