Provider Demographics
NPI:1790194702
Name:KONITZER, KENDRA E (PA)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:E
Last Name:KONITZER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KENDRA
Other - Middle Name:E
Other - Last Name:BLIESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:GYNECOLOGIC ONCOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8570
Mailing Address - Fax:414-805-6622
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:GYNECOLOGIC ONCOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8570
Practice Address - Fax:414-805-6622
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1790194702Medicaid