Provider Demographics
NPI:1932104478
Name:HEERENS-KNUDSON, NANCY A (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:A
Last Name:HEERENS-KNUDSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:608-775-4467
Practice Address - Street 1:1330 N SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:TOMAH
Practice Address - State:WI
Practice Address - Zip Code:54660-1130
Practice Address - Country:US
Practice Address - Phone:608-372-4111
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1744363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41992900Medicaid
R81054Medicare UPIN