Provider Demographics
NPI:1811104557
Name:WOGAHN, KRISTIN S (MD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:S
Last Name:WOGAHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 W HAMILTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6970
Mailing Address - Country:US
Mailing Address - Phone:715-552-9784
Mailing Address - Fax:715-835-6370
Practice Address - Street 1:3802 OAKWOOD MALL DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3016
Practice Address - Country:US
Practice Address - Phone:715-839-9280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36398-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32111000Medicaid
WI32111000Medicaid
WIK400139378Medicare PIN