Basic Information
| Provider Information | |||||||||
| NPI: | 1780742197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NATHAN | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAJERUS | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 204 LUNDORFF DR | ||||||||
| Address2: | |||||||||
| City: | SANDSTONE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550725051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 LUNDORFF DR | ||||||||
| Address2: | |||||||||
| City: | SANDSTONE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550725051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202452250 | ||||||||
| FaxNumber: | 3202452555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 01/03/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1876 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42870500 | 05 | WI | MEDICAID |