Provider Demographics
NPI:1831619279
Name:SMITH, KATHRYN (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:YARGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1111 DELAFIELD STREET
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3407
Mailing Address - Country:US
Mailing Address - Phone:262-544-4411
Mailing Address - Fax:262-650-3856
Practice Address - Street 1:1111 DELAFIELD STREET
Practice Address - Street 2:SUITE 120
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3407
Practice Address - Country:US
Practice Address - Phone:262-544-4411
Practice Address - Fax:262-650-3856
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
WI4044-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100071249Medicaid
WI1831619279Medicaid