Healthcare Provider Details

I. General information

NPI: 1700452117
Provider Name (Legal Business Name): KATELYNN KNIPPER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 CEDAR CROSS RD
DUBUQUE IA
52003-7704
US

IV. Provider business mailing address

535 CEDAR CROSS RD
DUBUQUE IA
52003-7704
US

V. Phone/Fax

Practice location:
  • Phone: 563-588-0506
  • Fax:
Mailing address:
  • Phone: 563-588-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number107503
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5437-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: