Basic Information
| Provider Information | |||||||||
| NPI: | 1821522202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKENANDORE | ||||||||
| FirstName: | COLTON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 164 N. BROADWAY | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543032728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204909046 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2845 GREENBRIER RD | ||||||||
| Address2: | |||||||||
| City: | GREEN BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 543116519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202888000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2017 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 4033-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100068094 | 05 | WI | MEDICAID |