Provider Demographics
NPI:1720034267
Name:GOERGEN, ASHELEY ROBYN (PAC)
Entity Type:Individual
Prefix:
First Name:ASHELEY
Middle Name:ROBYN
Last Name:GOERGEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ASHELEY
Other - Middle Name:ROBIN
Other - Last Name:KIEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6308 8TH AVENUE
Mailing Address - Street 2:ATTN: MEDICAL STAFF OFFICE
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143
Mailing Address - Country:US
Mailing Address - Phone:262-656-2218
Mailing Address - Fax:262-653-5850
Practice Address - Street 1:9555 76TH ST STE 1200
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1984
Practice Address - Country:US
Practice Address - Phone:262-671-7300
Practice Address - Fax:262-671-7315
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1881-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42874700Medicaid
WI42874700Medicaid
WI008532250Medicare PIN