Provider Demographics
NPI:1316959083
Name:RAGUSE, BRIAN R (PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:RAGUSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 KEPLER DR
Mailing Address - Street 2:PO BOX 8970
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54308-8970
Mailing Address - Country:US
Mailing Address - Phone:920-288-5555
Mailing Address - Fax:920-288-5550
Practice Address - Street 1:1160 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-288-5555
Practice Address - Fax:920-288-5550
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41980900Medicaid
018707650Medicare ID - Type Unspecified
Q01308Medicare UPIN
WI005171460Medicare PIN