Provider Demographics
NPI:1336235522
Name:PEDRIANA, KATHRINE E (PA)
Entity Type:Individual
Prefix:
First Name:KATHRINE
Middle Name:E
Last Name:PEDRIANA
Suffix:
Gender:F
Credentials:PA
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 778789
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8789
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:
Practice Address - Street 1:2906 S 20TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3732
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:414-672-0191
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIPA10004672363A00000X
WAPA10004672363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6684PEOtherREGENCE
911019392OtherCOMMERCIAL
WA8937049OtherCRIME VICTIMS
WA0188183OtherL & I
WA8405490OtherCHPW
WA8405490Medicaid
Q24609Medicare UPIN
WA8405490Medicaid
G8806651Medicare ID - Type Unspecified