Healthcare Provider Details

I. General information

NPI: 1346783396
Provider Name (Legal Business Name): KATIE CARLSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2016
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8840 CALUMET AVE SUITE 103
MUNSTER IN
46321-2545
US

IV. Provider business mailing address

2741 W LAYTON AVE STE 106
MILWAUKEE WI
53221-2600
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-7246
  • Fax:
Mailing address:
  • Phone: 414-242-5468
  • Fax: 888-724-0875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002162A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: