Provider Demographics
NPI:1699885756
Name:KOERTEN, KRISTIN (PAC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:KOERTEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:
Other - Last Name:FALKENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:920-433-8389
Practice Address - Fax:920-431-3667
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY42871000Medicaid
WY42871000Medicaid
Q51580Medicare UPIN