Healthcare Provider Details

I. General information

NPI: 1275867186
Provider Name (Legal Business Name): CATHERINE M PATEL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CATHERINE M LAURENT PAC

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54308-8900
US

IV. Provider business mailing address

164 N BROADWAY
GREEN BAY WI
54303-2728
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-4060
  • Fax: 920-288-4067
Mailing address:
  • Phone: 920-288-4060
  • Fax: 920-288-4067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2736
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2736023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: