Provider Demographics
NPI:1083195580
Name:MAHONEY, KATHRYN A (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:MAHONEY
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 1:111 E WISCONSIN AVE STE 2000
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4809
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:9555 76TH ST # 1200
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-1984
Practice Address - Country:US
Practice Address - Phone:262-671-7300
Practice Address - Fax:262-671-7315
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4512-23363A00000X
IL085010142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1083195580Medicaid
WI4512-23OtherWI LICENSE