Provider Demographics
NPI:1477888006
Name:ZELLNER, KATIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:ZELLNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:L
Other - Last Name:VANDENBOOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:NEOPLASTIC DISEASES
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6817
Mailing Address - Fax:414-805-6815
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:NEOPLASTIC DISEASES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6817
Practice Address - Fax:414-805-6815
Is Sole Proprietor?:No
Enumeration Date:2009-10-15
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2520363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1477888006Medicaid
WI736011599Medicare PIN