Provider Demographics
NPI:1275867186
Name:PATEL, CATHERINE M (PAC)
Entity Type:Individual
Prefix:MRS
First Name:CATHERINE
Middle Name:M
Last Name:PATEL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:CATHERINE
Other - Middle Name:M
Other - Last Name:LAURENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:164 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2728
Mailing Address - Country:US
Mailing Address - Phone:920-288-4060
Mailing Address - Fax:920-288-4067
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54308-8900
Practice Address - Country:US
Practice Address - Phone:920-288-4060
Practice Address - Fax:920-288-4067
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2736023363AM0700X
WI2736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275867186Medicaid
WI1275867186Medicaid