Provider Demographics
NPI:1861917098
Name:RUNNOE, AMBER DEE (PA-C)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:DEE
Last Name:RUNNOE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:DEE
Other - Last Name:AHLQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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 1:2500 E CAPITOL DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-364-3600
Practice Address - Fax:920-364-3900
Is Sole Proprietor?:No
Enumeration Date:2017-08-09
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4143-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant