Healthcare Provider Details

I. General information

NPI: 1710936588
Provider Name (Legal Business Name): KATIE R. FASSBINDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 AIRPORT RD
VIROQUA WI
54665-1159
US

IV. Provider business mailing address

210 AIRPORT RD PO BOX 189
VIROQUA WI
54665-1159
US

V. Phone/Fax

Practice location:
  • Phone: 608-638-7420
  • Fax: 608-638-7429
Mailing address:
  • Phone: 608-638-7420
  • Fax: 608-638-7429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1343-TEP
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number49741
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: