Provider Demographics
NPI:1639665193
Name:STAHNKE, ANTONETTE K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANTONETTE
Middle Name:K
Last Name:STAHNKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANTONETTE
Other - Middle Name:RENEE
Other - Last Name:KNAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:920-327-7300
Mailing Address - Fax:920-327-7301
Practice Address - Street 1:2253 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4706
Practice Address - Country:US
Practice Address - Phone:920-327-7300
Practice Address - Fax:920-327-7301
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI4940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100100258Medicaid