Provider Demographics
NPI:1851316871
Name:BALTHAZOR, BRENDA K (PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:K
Last Name:BALTHAZOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4147
Mailing Address - Country:US
Mailing Address - Phone:715-847-2021
Mailing Address - Fax:715-847-2325
Practice Address - Street 1:512 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4147
Practice Address - Country:US
Practice Address - Phone:715-847-2021
Practice Address - Fax:715-847-2325
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI186923363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42871300Medicaid
WI42871300Medicaid