Provider Demographics
NPI:1679463905
Name:BUBOLTZ, MEGAN (PA-C)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:BUBOLTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S24W36087 COUNTRYSIDE CT
Mailing Address - Street 2:
Mailing Address - City:DOUSMAN
Mailing Address - State:WI
Mailing Address - Zip Code:53118-9688
Mailing Address - Country:US
Mailing Address - Phone:262-313-8602
Mailing Address - Fax:
Practice Address - Street 1:S24W36087 COUNTRYSIDE CT
Practice Address - Street 2:
Practice Address - City:DOUSMAN
Practice Address - State:WI
Practice Address - Zip Code:53118-9688
Practice Address - Country:US
Practice Address - Phone:262-313-8602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI8478-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant