Provider Demographics
NPI:1770522948
Name:CHRISTOFFERSON, BRIAN (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CHRISTOFFERSON
Suffix:
Gender:M
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 1:8901 N 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-1901
Mailing Address - Country:US
Mailing Address - Phone:414-354-0772
Mailing Address - Fax:414-365-0773
Practice Address - Street 1:8901 N 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-1901
Practice Address - Country:US
Practice Address - Phone:414-354-0772
Practice Address - Fax:414-365-0773
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1153-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42988900Medicaid
WI42988900Medicaid