Provider Demographics
NPI:1811018468
Name:KOHL, BECKY LYNN JARACZ (MS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:LYNN JARACZ
Last Name:KOHL
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
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Mailing Address - Street 1:4826 ACADEMY DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1452
Mailing Address - Country:US
Mailing Address - Phone:608-268-3683
Mailing Address - Fax:
Practice Address - Street 1:611 E SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1960
Practice Address - Country:US
Practice Address - Phone:920-568-5330
Practice Address - Fax:920-568-5075
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1576023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43023100Medicaid
WI43023100Medicaid