Provider Demographics
NPI:1760433189
Name:NASHOLD, BRENDAN J (PA-C)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:J
Last Name:NASHOLD
Suffix:
Gender:M
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 1:130 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3116
Mailing Address - Country:US
Mailing Address - Phone:920-877-3102
Mailing Address - Fax:920-885-8790
Practice Address - Street 1:130 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3116
Practice Address - Country:US
Practice Address - Phone:920-877-3102
Practice Address - Fax:920-885-8790
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI861-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760433189Medicaid
WIK400177044Medicare PIN
WI1760433189Medicaid
WI4949OtherDEAN HEALTH INSURANCE
WIK400136402Medicare PIN
WI42956000Medicaid
WI970031054Medicare PIN
S08062Medicare UPIN