Basic Information
| Provider Information | |||||||||
| NPI: | 1437477320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASCONCELLOS | ||||||||
| FirstName: | KATE | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493240 | ||||||||
| FaxNumber: | 4146493244 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 W KINNICKINNIC RIVER PKWY STE 575 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532155200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146493240 | ||||||||
| FaxNumber: | 4146493244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2010 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 94-07351 | KS | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 76842 | GA | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208C00000X | 22706 | WI | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100208986 | 05 | WI | MEDICAID |