Provider Demographics
NPI:1104186048
Name:JULIEN, KEGAN D (PA-C)
Entity type:Individual
Prefix:
First Name:KEGAN
Middle Name:D
Last Name:JULIEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6850
Mailing Address - Fax:414-805-6851
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6850
Practice Address - Fax:414-805-6851
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI2991-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1104186048Medicaid
WIK400102848Medicare PIN
WI1104186048Medicaid