Provider Demographics
NPI:1881661577
Name:HAFEMANN, KALYN R (PA-C)
Entity Type:Individual
Prefix:
First Name:KALYN
Middle Name:R
Last Name:HAFEMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KALYN
Other - Middle Name:R
Other - Last Name:MOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:788 N. JEFFERSON STREET,
Mailing Address - Street 2:SUITE 300/ATTN: KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3710
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:788 N. JEFFERSON STREET
Practice Address - Street 2:SUITE 401
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3710
Practice Address - Country:US
Practice Address - Phone:414-226-4020
Practice Address - Fax:414-225-2929
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1288363A00000X
WI1288-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1881661577Medicaid
WI1881661577Medicaid
WI1881661577Medicaid