Provider Demographics
NPI:1013690684
Name:HAASCH, KATELYN VANA (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:VANA
Last Name:HAASCH
Suffix:
Gender:F
Credentials:PA-C
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235-6053
Practice Address - Country:US
Practice Address - Phone:414-744-7880
Practice Address - Fax:414-294-4570
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100262861Medicaid