Provider Demographics
NPI:1902104326
Name:SABLE, BRIANNE M (PA)
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:M
Last Name:SABLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRIANNE
Other - Middle Name:M
Other - Last Name:BRECKHEIMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:1615 MAPLE LANE, SUITE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2721363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01277534OtherRR MEDICARE
WI462364768Medicare PIN
WI019940542Medicare PIN