Basic Information
| Provider Information | |||||||||
| NPI: | 1376679092 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUDAS | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10001 W INNOVATION DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532264851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
| FaxNumber: | 4142382424 | ||||||||
| Practice Location | |||||||||
| Address1: | 2885 N MAYFAIR RD | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532224404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147716780 | ||||||||
| FaxNumber: | 4142382424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1405 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 41932600 | 05 | WI | MEDICAID |