Provider Demographics
NPI:1578597035
Name:BROWN, LISETTE C (PA C)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:C
Last Name:BROWN
Suffix:
Gender:F
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:421 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-926-8500
Practice Address - Fax:920-926-8983
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1623023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41993300Medicaid
WI001OtherBCBS
WI3880212501OtherBLUE SHIELD
WI41993300Medicaid
WI41993300Medicaid
WI008202905Medicare PIN
WI025801940Medicare PIN
WI0082Medicare PIN
WI$$$$$$$$$001OtherBLUE SHIELD