Provider Demographics
NPI:1083724330
Name:NOELLER, KATHERINE R (DPM)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:R
Last Name:NOELLER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25405 HANCOCK AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5978
Mailing Address - Country:US
Mailing Address - Phone:951-677-1323
Mailing Address - Fax:888-716-6560
Practice Address - Street 1:25405 HANCOCK AVE STE 105
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5978
Practice Address - Country:US
Practice Address - Phone:951-677-1323
Practice Address - Fax:888-716-6560
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2997213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E29970Medicaid
CA5505570001Medicare NSC
000E29970Medicare ID - Type Unspecified
CA000E29970Medicaid