Provider Demographics
NPI:1720026339
Name:FARNSWORTH, KELLEY E (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:E
Last Name:FARNSWORTH
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 1:960 N 12TH ST
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1306
Mailing Address - Country:US
Mailing Address - Phone:414-278-9000
Mailing Address - Fax:414-278-9005
Practice Address - Street 1:960 N 12TH ST
Practice Address - Street 2:SUITE 1800
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1306
Practice Address - Country:US
Practice Address - Phone:414-278-9000
Practice Address - Fax:414-278-9005
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1051-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42982600Medicaid
WIS73276Medicare UPIN