Healthcare Provider Details

I. General information

NPI: 1457828238
Provider Name (Legal Business Name): KATIE MISCHKE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE DEMARAIS PA

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1333 W 5TH ST STE 113
SHERIDAN WY
82801-2752
US

IV. Provider business mailing address

1333 W 5TH ST STE 110
SHERIDAN WY
82801-2752
US

V. Phone/Fax

Practice location:
  • Phone: 307-675-2633
  • Fax: 307-675-2634
Mailing address:
  • Phone: 307-675-2633
  • Fax: 307-675-2634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPT1355
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: