Provider Demographics
NPI:1316995566
Name:PLANKENHORN, CAROL M (PA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:PLANKENHORN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 W OKLAHOMA AVE
Mailing Address - Street 2:ERMED, ST. LUKE'S MEDICAL CENTER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-4330
Mailing Address - Country:US
Mailing Address - Phone:414-649-7299
Mailing Address - Fax:
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:ERMED
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-649-7299
Practice Address - Fax:414-649-6694
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1187-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIPOO41817Medicaid
WIPOO41817Medicaid
WIPOO41817Medicaid
P00041817Medicare PIN
WI021501940Medicare PIN