Provider Demographics
NPI:1780742197
Name:NATHAN, KATHERINE ANN (PA)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:NATHAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:MAJERUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 LUNDORFF DR
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-5051
Mailing Address - Country:US
Mailing Address - Phone:320-245-2250
Mailing Address - Fax:320-245-2555
Practice Address - Street 1:204 LUNDORFF DR
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-5051
Practice Address - Country:US
Practice Address - Phone:320-245-2250
Practice Address - Fax:320-245-2555
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1876363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42870500Medicaid
WIP73506Medicare UPIN
WI003300498Medicare PIN
WI42870500Medicaid