Provider Demographics
NPI:1336450949
Name:BURKERT, KRISTIN N (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:N
Last Name:BURKERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:N
Other - Last Name:HARWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3077 N MAYFAIR RD STE 305
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-4305
Mailing Address - Country:US
Mailing Address - Phone:414-384-6700
Mailing Address - Fax:414-727-1058
Practice Address - Street 1:3077 N MAYFAIR RD STE 305
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4305
Practice Address - Country:US
Practice Address - Phone:414-384-6700
Practice Address - Fax:414-727-1058
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2581-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336450949Medicaid
WI012950042Medicare PIN