Provider Demographics
NPI:1033465679
Name:PETHAN, KIRSTEN D (PA-C)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:D
Last Name:PETHAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 W CALUMET ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-4934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:833-972-1585
Practice Address - Street 1:145 W CALUMET ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-4934
Practice Address - Country:US
Practice Address - Phone:920-967-4141
Practice Address - Fax:833-972-1585
Is Sole Proprietor?:No
Enumeration Date:2012-08-01
Last Update Date:2025-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5206363A00000X
MN11202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970006408Medicare PIN