Basic Information
| Provider Information | |||||||||
| NPI: | 1154586717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNIPFER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 251 E COTTAGE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535279619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088393515 | ||||||||
| FaxNumber: | 6088393541 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 E COTTAGE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535279619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088393515 | ||||||||
| FaxNumber: | 6088393541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2313-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1154586717 | 05 | WI | MEDICAID |