Provider Demographics
NPI:1174547244
Name:SHEFCHIK, KIM MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:SHEFCHIK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:M
Other - Last Name:DALEBROUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7226
Mailing Address - Fax:920-445-7229
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:STE. 300
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-468-3444
Practice Address - Fax:920-432-6313
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32400300Medicaid
1054037OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
P73676Medicare UPIN