Provider Demographics
NPI:1346783396
Name:CARLSON, KATIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 W LAYTON AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-2600
Mailing Address - Country:US
Mailing Address - Phone:414-242-5468
Mailing Address - Fax:888-724-0875
Practice Address - Street 1:8840 CALUMET AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2545
Practice Address - Country:US
Practice Address - Phone:219-836-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002162A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant