Provider Demographics
NPI:1154377091
Name:MOTTINGER, KEVEN R (PAC)
Entity type:Individual
Prefix:
First Name:KEVEN
Middle Name:R
Last Name:MOTTINGER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4536 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-5917
Mailing Address - Country:US
Mailing Address - Phone:262-656-0044
Mailing Address - Fax:262-653-2218
Practice Address - Street 1:3400 MARKET LN
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3430
Practice Address - Country:US
Practice Address - Phone:262-551-4600
Practice Address - Fax:262-551-4630
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1868363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12006222OtherCAQH
12006222OtherCAQH
WI42872900Medicaid
12006222OtherCAQH
WI42872900Medicaid