NPIMap

Individual provider Active NPI

Kelly Rae Vandermuss, PA-C

  • Physician Assistant
  • De Pere, WI
National Provider Identifier
1760042923
Registry record updated Dec 5, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
4704-23 Issued in WI
Practice address
1381 Brayden LN
De Pere, WI 54115-9249
Phone
(920) 664-3734
NPI assigned
Jun 19, 2019
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 5, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 4704-23 WI Primary

Addresses

Primary practice location

1381 Brayden LN
De Pere, WI 54115-9249

Mailing address

2502 S Ashland Ave
Green Bay, WI 54304-5252
Phone (920) 496-4700

Other names 1

  • Kelly Rae Marble Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20190711000451 WI Practitioner - Physician Assistant 7618202763 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2009
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices

Practice addresses (Care Compare)

1821 S Webster Ave
Green Bay, WI 54301-2253
Phone (920) 496-4700

835 S Van Buren St
Green Bay, WI 54301-3526
Phone (920) 496-4700

Hospital & facility affiliations

  • St Vincent Hospital Hospital, Green Bay, WI, CCN 520075

Merit-based Incentive Payment System (MIPS)

Final score
94.81 of 100Reported as apm
Quality
85.98
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
4704-23WIMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
St Nicholas Hospital-Sisters of the Third Order of St Francis CurrentSince Jul 1, 2019 Accepting new patients
St Vincent Hospital-Hospital Sisters-Third Order of St Francis CurrentSince Jul 1, 2019 Accepting new patients
St Clare Memorial Hospital, Inc CurrentSince Dec 1, 2019 Accepting new patients
St. Clare Memorial Hospital, Inc CurrentSince Dec 1, 2019 Accepting new patients
Prevea Clinic, Inc. CurrentSince Jul 1, 2019 Accepting new patients
St. Nicholas Hospital-Sisters of the Third Order of St Francis CurrentSince Jul 1, 2019 Accepting new patients
St Vincent Hospital-Hospital Sisters-Third Order of St Francis CurrentSince Jul 1, 2019 Accepting new patients
St Vincent Hospital-Hospital Sisters-Third Order of St Francis Past Accepting new patients

Locations

1726 Shawano Ave
Green Bay, WI 54303
Phone (920) 432-6016

1821 S Webster Ave
Green Bay, WI 54301
Phone (920) 431-1850

835 S Van Buren St
Green Bay, WI 54301
Phone (888) 901-7246

2502 S Ashland Ave
Green Bay, WI 54304
Phone (920) 496-4750

855 S Main St
Ste 1
Oconto Falls, WI 54154
Phone (920) 846-8187

3100 Superior Ave
Sheboygan, WI 53081
Phone (800) 472-6710

Organizations & group practices 10

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1560902400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1575504000000",
    "number": "1760042923",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2502 S ASHLAND AVE",
            "city": "GREEN BAY",
            "state": "WI",
            "postal_code": "543045252",
            "telephone_number": "920-496-4700"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1381 BRAYDEN LN",
            "city": "DE PERE",
            "state": "WI",
            "postal_code": "541159249",
            "telephone_number": "920-664-3734"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VANDERMUSS",
        "first_name": "KELLY",
        "middle_name": "RAE",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-06-19",
        "last_updated": "2019-12-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "WI",
            "license": "4704-23",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "KELLY",
            "last_name": "MARBLE",
            "middle_name": "RAE",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in De Pere, WI

Sources for this page

Verify at the official NPI Registry.