Provider Demographics
NPI:1598310849
Name:BOPP, CATHERINE M (PAC)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:M
Last Name:BOPP
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78866
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53278-8866
Mailing Address - Country:US
Mailing Address - Phone:779-696-7150
Mailing Address - Fax:
Practice Address - Street 1:1340 CHARLES ST STE 100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2200
Practice Address - Country:US
Practice Address - Phone:779-696-8700
Practice Address - Fax:779-696-8745
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-007148363A00000X, 363AS0400X
WI7305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100247750Medicaid