Provider Demographics
NPI:1649231085
Name:BRAAM, KYLIE LYNN (PA)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:LYNN
Last Name:BRAAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:LYNN
Other - Last Name:GASPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6716
Mailing Address - Fax:414-456-6515
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6716
Practice Address - Fax:414-456-6515
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1507023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1649231085Medicaid
WI41961100Medicaid