Provider Demographics
NPI:1104371897
Name:TETZLAFF, KATIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:TETZLAFF
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 1:400 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-2450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 22ND AVE
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2450
Practice Address - Country:US
Practice Address - Phone:605-697-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1294363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant