Basic Information
| Provider Information | |||||||||
| NPI: | 1831199439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUANDT-WALLE | ||||||||
| FirstName: | CRAIG | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 88215 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1818 N MEADE ST | ||||||||
| Address2: | |||||||||
| City: | APPLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549113454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009686866 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 01/22/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1346023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 41930500 | 05 | WI | MEDICAID |