Provider Demographics
NPI:1700414711
Name:VERKUILEN, CARISSA (PA-C)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:
Last Name:VERKUILEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:
Other - Last Name:ROHDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1900 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5467
Mailing Address - Country:US
Mailing Address - Phone:608-775-8388
Mailing Address - Fax:
Practice Address - Street 1:1900 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5467
Practice Address - Country:US
Practice Address - Phone:608-775-8388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI5518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant