Basic Information
Provider Information | |||||||||
NPI: | 1174547244 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHEFCHIK | ||||||||
FirstName: | KIM | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DALEBROUX | ||||||||
OtherFirstName: | KIM | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 22487 | ||||||||
Address2: |   | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543052487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204457226 | ||||||||
FaxNumber: | 9204457229 | ||||||||
Practice Location | |||||||||
Address1: | 704 S WEBSTER AVE | ||||||||
Address2: | STE. 300 | ||||||||
City: | GREEN BAY | ||||||||
State: | WI | ||||||||
PostalCode: | 543013528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9204683444 | ||||||||
FaxNumber: | 9204326313 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2006 | ||||||||
LastUpdateDate: | 12/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1484 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 32400300 | 05 | WI |   | MEDICAID | 1054037 | 01 |   | NATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS | OTHER |