MEDICARE: CATIE FERN PONTEL PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302R00000X	Health Maintenance Organization	1652-019	WI

General Provider Information

NPI Number	:	1396010468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CATIE FERN PONTEL PTA

Provider Business Mailing Address
First Line	:	W4929 PADDOCK DR
Second Line	:
City	:	ELKHORN
State	:	WI
Zip	:	53121-3106
Country	:	US
Telephone Number	:	414-687-9526
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 RIDGE RD
Second Line	:
City	:	WALWORTH
State	:	WI
Zip	:	53184-9526
Country	:	US
Telephone Number	:	262-275-2317
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2012
Last Update Date	:	08/27/2012

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