Provider Demographics
NPI:1639664642
Name:LOIS, VICTORIA ROBYN (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROBYN
Last Name:LOIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ROBYN
Other - Last Name:INTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WILD ROSE
Mailing Address - State:WI
Mailing Address - Zip Code:54984-6901
Mailing Address - Country:US
Mailing Address - Phone:920-622-5560
Mailing Address - Fax:920-662-6021
Practice Address - Street 1:701 GROVE AVE
Practice Address - Street 2:
Practice Address - City:WILD ROSE
Practice Address - State:WI
Practice Address - Zip Code:54984-6901
Practice Address - Country:US
Practice Address - Phone:920-622-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-22
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant