Provider Demographics
NPI:1205823630
Name:GATZKE, MARY K (DNP)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:K
Last Name:GATZKE
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5726 COUNTY T
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-9140
Mailing Address - Country:US
Mailing Address - Phone:920-253-6582
Mailing Address - Fax:
Practice Address - Street 1:W5726 COUNTY T
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-9140
Practice Address - Country:US
Practice Address - Phone:920-253-6582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2426033363L00000X
MI4704241650363L00000X
WI2426-33363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00124270OtherRR - MEDICARE
MIN97840001OtherMEDICAID
WI43999100Medicaid
WI4825080003Medicare NSC
Q12693Medicare UPIN
WI43999100Medicaid