Provider Demographics
NPI:1881974947
Name:SKJERVEM, KRISTA K (PAC)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:K
Last Name:SKJERVEM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:K
Other - Last Name:ERICSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:414-805-6851
Practice Address - Street 1:202 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1507
Practice Address - Country:US
Practice Address - Phone:608-417-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2828363A00000X
WI2828-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1881974947Medicaid
WI736012273Medicare PIN
WI680861050Medicare PIN