Provider Demographics
NPI:1568420404
Name:SHOOKMAN, THOMAS W (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:SHOOKMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 TUTTLE ST
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-3319
Mailing Address - Country:US
Mailing Address - Phone:608-355-3800
Mailing Address - Fax:608-355-7001
Practice Address - Street 1:1700 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3319
Practice Address - Country:US
Practice Address - Phone:608-355-3800
Practice Address - Fax:608-355-7001
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3421OtherDEAN HEALTH INSURANCE
WI42976900Medicaid
WI1027534OtherPHYSICIANS PLUS
WI970022609Medicare PIN
WI005157155Medicare PIN
WI42976900Medicaid
WI3421OtherDEAN HEALTH INSURANCE