Basic Information
| Provider Information | |||||||||
| NPI: | 1356414668 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KETTERHAGEN | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANNA | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1446 N RANDALL AVE | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535451122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6087587215 | ||||||||
| FaxNumber: | 6087583216 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 E RACINE ST | ||||||||
| Address2: | |||||||||
| City: | JANESVILLE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535462343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6083718000 | ||||||||
| FaxNumber: | 6083718008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1757-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 41992300 | 05 | WI | MEDICAID | 61167 | 01 | WI | DEAN HEALTH SYSTEMS, INC | OTHER |