Provider Demographics
NPI:1265492888
Name:DAHLK, MARLA (PAC)
Entity type:Individual
Prefix:
First Name:MARLA
Middle Name:
Last Name:DAHLK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 BRIGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-1203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3705 BRIGHAM AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-1203
Practice Address - Country:US
Practice Address - Phone:608-320-0938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI542363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical