Provider Demographics
NPI:1487605937
Name:CRONIN, DOUGLAS J (PA-C)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:CRONIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S UNIVERSITY AVE
Mailing Address - Street 2:STE 510
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-3081
Mailing Address - Country:US
Mailing Address - Phone:920-887-3102
Mailing Address - Fax:920-885-8788
Practice Address - Street 1:705 S UNIVERSITY AVE
Practice Address - Street 2:STE 510
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-3081
Practice Address - Country:US
Practice Address - Phone:920-887-3102
Practice Address - Fax:920-885-8788
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI2055OtherDEAN HEALTH INSURANCE
WI1001738OtherPHYSICIANS PLUS
WI42905400Medicaid
WI008054375Medicare PIN
WI970022639Medicare PIN
WI132150113Medicare PIN
R82973Medicare UPIN
WI007313215Medicare PIN