Provider Demographics
NPI:1851521884
Name:STEWART, KATIE R (PAC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:R
Last Name:STEWART
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:R
Other - Last Name:ASP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1526 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-2245
Mailing Address - Country:US
Mailing Address - Phone:608-781-9880
Mailing Address - Fax:
Practice Address - Street 1:1526 ROSE ST
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-2245
Practice Address - Country:US
Practice Address - Phone:608-781-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3421-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical