Provider Demographics
NPI:1881659340
Name:CONKLIN, VIRGINIA L (CRNA)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:L
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1849
Mailing Address - Country:US
Mailing Address - Phone:608-258-6975
Mailing Address - Fax:608-258-5222
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1849
Practice Address - Country:US
Practice Address - Phone:608-258-6975
Practice Address - Fax:608-258-5222
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI141913-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1881659340Medicaid
WI44332900Medicaid
WI543401697Medicare PIN
WI60285OtherDEAN HEALTH INSURANCE
Q26819Medicare UPIN
WIP00455548Medicare PIN