Basic Information
| Provider Information | |||||||||
| NPI: | 1932637444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAY | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4909 W TUMBLE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531328392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9205170717 | ||||||||
| FaxNumber: | 4148056808 | ||||||||
| Practice Location | |||||||||
| Address1: | 9200 W WISCONSIN AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532263522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4148059728 | ||||||||
| FaxNumber: | 4148056808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2017 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 769133 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1932637444 | 05 | WI | MEDICAID | 769133 | 01 | WI | APNP STATE LICENSE | OTHER |