Provider Demographics
NPI:1154883593
Name:LIETZAU, KRISTIN K (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:K
Last Name:LIETZAU
Suffix:
Gender:F
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BELOIT CLINIC
Mailing Address - Street 2:1905 E. HUEBBE PARKWAY
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-2293
Mailing Address - Fax:608-364-5452
Practice Address - Street 1:BELOIT CLINIC
Practice Address - Street 2:1905 E. HUEBBE PARKWAY
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-2230
Practice Address - Fax:608-363-7394
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007026207XX0005X
IL085-007026363A00000X
WI4671-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine