Provider Demographics
NPI:1508187436
Name:SCHULTZ, LAURA B (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:B
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:B
Other - Last Name:BERKEVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:105 HIGHLAND TER
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:WI
Mailing Address - Zip Code:53594-2217
Mailing Address - Country:US
Mailing Address - Phone:920-478-2141
Mailing Address - Fax:920-478-3820
Practice Address - Street 1:105 HIGHLAND TER
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:WI
Practice Address - Zip Code:53594-2217
Practice Address - Country:US
Practice Address - Phone:920-478-2141
Practice Address - Fax:920-478-3820
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2590-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508187436Medicaid