=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316568504
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATE DOBBERSTEIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2020
-----------------------------------------------------
Last Update Date | 04/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2105 E ENTERPRISE AVE STE 113
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54913-7862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-216-6171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1151 BARBARY LN
-----------------------------------------------------
City | WINNECONNE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54986-9660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-216-6171
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | 536336
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------