NPIMap

Individual provider Active NPI

Blayne S Kozelka, PA-C

  • Surgical Physician Assistant
  • La Crosse, WI
National Provider Identifier
1871078667
Registry record updated Oct 12, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Surgical Physician AssistantTaxonomy code 363AS0400X
License
4522 Issued in WI
Practice address
1836 South Ave
La Crosse, WI 54601-5429
Phone
(608) 782-7300
NPI assigned
Sep 27, 2018
Last updated
Oct 12, 2018By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2018

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Surgical Physician Assistant 363AS0400X 4522 WI Primary

Addresses

Primary practice location

1836 South Ave
La Crosse, WI 54601-5429

Mailing address

1836 South Ave
La Crosse, WI 54601-5429
Phone (608) 782-7300

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
I20181105000571 WI Practitioner - Physician Assistant 9436402633 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2018
Medicare assignment
May accept Medicare assignment

Practice addresses (Care Compare)

1836 S Ave
La Crosse, WI 54601

Hospital & facility affiliations

National Provider Directory

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

State licenses

LicenseStateTypeSpecialty
4522WIMDSurgical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Gundersen Lutheran Express Care, Inc CurrentSince Oct 22, 2018 Accepting new patients
Gundersen Clinic, LTD. CurrentSince Oct 22, 2018 Accepting new patients
Gundersen Lutheran Medical Center, Inc. Past Accepting new patients

Locations

1836 South Ave
La Crosse, WI 54601
Phone (608) 788-8102

1910 South Ave
La Crosse, WI 54601
Phone (608) 775-2287

1600 Main St
Onalaska, WI 54650
Phone (608) 783-4681

Interoperability endpoints

  • Direct secure messaging: bkozelka25561@direct.emplifyhealth.org

Organizations & group practices 4

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

Hospital & facility affiliations 8

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": "1538006400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1539302400000",
    "number": "1871078667",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1836 SOUTH AVE",
            "city": "LA CROSSE",
            "state": "WI",
            "postal_code": "546015429",
            "telephone_number": "608-782-7300"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1836 SOUTH AVE",
            "city": "LA CROSSE",
            "state": "WI",
            "postal_code": "546015429",
            "telephone_number": "608-782-7300"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KOZELKA",
        "first_name": "BLAYNE",
        "middle_name": "S",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2018-09-27",
        "last_updated": "2018-10-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "WI",
            "license": "4522",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in La Crosse, WI

Sources for this page

Verify at the official NPI Registry.