Healthcare Provider Details

I. General information

NPI: 1316568504
Provider Name (Legal Business Name): KATE DOBBERSTEIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2020
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E ENTERPRISE AVE STE 113
APPLETON WI
54913-7862
US

IV. Provider business mailing address

1151 BARBARY LN
WINNECONNE WI
54986-9660
US

V. Phone/Fax

Practice location:
  • Phone: 920-216-6171
  • Fax:
Mailing address:
  • Phone: 920-216-6171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number536336
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: