Provider Demographics
NPI:1568500650
Name:BREITENFELD, MICHAEL L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BREITENFELD
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 1:105 4TH AVENUE
Mailing Address - Street 2:PO BOX 336
Mailing Address - City:SHELL L AKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871-0336
Mailing Address - Country:US
Mailing Address - Phone:715-468-2711
Mailing Address - Fax:715-468-2727
Practice Address - Street 1:105 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:SHELL L AKE
Practice Address - State:WI
Practice Address - Zip Code:54871-0336
Practice Address - Country:US
Practice Address - Phone:715-468-2711
Practice Address - Fax:715-468-2727
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI03-023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42906200Medicaid
WI42906200Medicaid