Provider Demographics
NPI:1396796660
Name:HIETPAS, JILL MARIE (PA C)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:HIETPAS
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:N2611 HUSS CT
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:WI
Mailing Address - Zip Code:54130-8674
Mailing Address - Country:US
Mailing Address - Phone:920-915-2669
Mailing Address - Fax:
Practice Address - Street 1:1835 E EDGEWOOD DR STE 10535
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9407
Practice Address - Country:US
Practice Address - Phone:920-215-0102
Practice Address - Fax:920-214-0795
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1285023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32494700Medicaid
WI32494700Medicaid