Provider Demographics
NPI:1497184279
Name:BALDERAS, KATIE JANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:JANE
Last Name:BALDERAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:JANE
Other - Last Name:SCHLOESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1033 N MAYFAIR RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3442
Mailing Address - Country:US
Mailing Address - Phone:414-454-0600
Mailing Address - Fax:
Practice Address - Street 1:1033 N MAYFAIR RD STE 101
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-3442
Practice Address - Country:US
Practice Address - Phone:414-454-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3253-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3253-23OtherSTATE LICENSE