Provider Demographics
NPI:1720394463
Name:HER, KONG (PA-C)
Entity Type:Individual
Prefix:
First Name:KONG
Middle Name:
Last Name:HER
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 1:3305 S 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4940
Mailing Address - Country:US
Mailing Address - Phone:414-645-1984
Mailing Address - Fax:
Practice Address - Street 1:3305 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4940
Practice Address - Country:US
Practice Address - Phone:414-645-1984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2740363A00000X
CAPA21104363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720394463Medicaid
WIK400367877/73975Medicare PIN