Provider Demographics
NPI:1356392237
Name:YENTZ, AUDRA L (PA-C)
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:L
Last Name:YENTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TOWER DR
Mailing Address - Street 2:
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590-1239
Mailing Address - Country:US
Mailing Address - Phone:608-825-3008
Mailing Address - Fax:608-825-3786
Practice Address - Street 1:10 TOWER DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1239
Practice Address - Country:US
Practice Address - Phone:608-825-3008
Practice Address - Fax:608-825-3786
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI652-023363AM0700X
WI652-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356392237Medicaid
WI2350OtherDEAN HEALTH INSURANCE
WI42935800Medicaid
WI970010925Medicare PIN
WI051674150Medicare PIN