Provider Demographics
NPI:1154528917
Name:MCGAVER, KATHERINE M (PAC)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:M
Last Name:MCGAVER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:M
Other - Last Name:LUETTGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:144 E SUMMIT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9546
Mailing Address - Country:US
Mailing Address - Phone:262-968-6161
Mailing Address - Fax:
Practice Address - Street 1:144 E SUMMIT AVE STE 100
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9546
Practice Address - Country:US
Practice Address - Phone:262-968-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00823740OtherRR MEDICARE
WI019940440Medicare PIN
WI462364674Medicare PIN