Provider Demographics
NPI:1558882555
Name:BROCKDORF, KRISTEN JEANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:JEANNE
Last Name:BROCKDORF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:JEANNE
Other - Last Name:BAUGNET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2500 E CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8735
Mailing Address - Country:US
Mailing Address - Phone:920-364-3600
Mailing Address - Fax:920-364-3900
Practice Address - Street 1:2500 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-364-3600
Practice Address - Fax:920-364-3900
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI249004246QM0706X
WI404123363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical