Provider Demographics
NPI:1528443108
Name:SPADY, JENNIFER L (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SPADY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:BIESTEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1310 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-1358
Mailing Address - Country:US
Mailing Address - Phone:608-253-1171
Mailing Address - Fax:608-253-8012
Practice Address - Street 1:1310 BROADWAY
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1358
Practice Address - Country:US
Practice Address - Phone:608-253-1171
Practice Address - Fax:608-253-8012
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3692-023363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528443108Medicaid
WIK400293714Medicare PIN
WI1528443108Medicaid