Provider Demographics
NPI:1255560553
Name:WOLDEN, KATHERINE ANNE (PAC)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:WOLDEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANNE
Other - Last Name:STILES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:5803 NEAL AVE N
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082-2177
Mailing Address - Country:US
Mailing Address - Phone:651-439-8807
Mailing Address - Fax:651-439-0232
Practice Address - Street 1:5803 NEAL AVE N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-2177
Practice Address - Country:US
Practice Address - Phone:651-439-8807
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2481-23363A00000X
MN10624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970004216Medicare PIN
WI1255560553Medicaid
MN1255560553Medicaid
WI56080-0044/491280043Medicare PIN