Provider Demographics
NPI:1649595547
Name:WOLTERS, KATIE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:WOLTERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:GOOSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:13955 GRANT PL
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-1208
Mailing Address - Country:US
Mailing Address - Phone:414-232-9540
Mailing Address - Fax:
Practice Address - Street 1:1032 E SUMNER ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:WI
Practice Address - Zip Code:53027-1608
Practice Address - Country:US
Practice Address - Phone:262-673-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63888-20207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology