Healthcare Provider Details

I. General information

NPI: 1629118211
Provider Name (Legal Business Name): KATHERINE ANN GONZAGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 01/04/2021
Certification Date: 01/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6408 COPPS AVE
MONONA WI
53716-3702
US

IV. Provider business mailing address

202 S PARK ST
MADISON WI
53715-1507
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number51711
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: