Provider Demographics
NPI:1548566391
Name:KANIKULA, AGNES M (PA)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:M
Last Name:KANIKULA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAIN
Mailing Address - State:WI
Mailing Address - Zip Code:53577-9668
Mailing Address - Country:US
Mailing Address - Phone:608-546-4211
Mailing Address - Fax:608-546-2440
Practice Address - Street 1:825 MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAIN
Practice Address - State:WI
Practice Address - Zip Code:53577-9668
Practice Address - Country:US
Practice Address - Phone:608-546-4211
Practice Address - Fax:608-546-2440
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2616-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant