Provider Demographics
NPI:1811354301
Name:WEIDNER, KATIE (RT(R)(CT))
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WEIDNER
Suffix:
Gender:F
Credentials:RT(R)(CT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2586 GEMINI RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-4608
Mailing Address - Country:US
Mailing Address - Phone:920-217-6212
Mailing Address - Fax:
Practice Address - Street 1:744 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3505
Practice Address - Country:US
Practice Address - Phone:920-433-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4276952471C3401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography