Provider Demographics
NPI:1619256401
Name:PAHL, VICTORIA D (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:D
Last Name:PAHL
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 1:2417 POST RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-6124
Mailing Address - Country:US
Mailing Address - Phone:715-690-1272
Mailing Address - Fax:715-544-1212
Practice Address - Street 1:420 DEWEY ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4714
Practice Address - Country:US
Practice Address - Phone:715-421-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1619256401Medicaid
WI1619256401Medicaid
WI736450070Medicare PIN