Basic Information
| Provider Information | |||||||||
| NPI: | 1104809839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAYES | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 E SHEBOYGAN ST | ||||||||
| Address2: | |||||||||
| City: | CAMPBELLSPORT | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530102795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205338361 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 12/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1168 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | WI01E6 | 01 | WI | JOHN DEERE | OTHER | 970009353 | 01 | WI | RAILROAD MEDICARE | OTHER | 39080723687 | 01 | WI | UNITY | OTHER | 42983500 | 05 | WI | MEDICAID | 12585 | 01 | WI | DEAN | OTHER |