Provider Demographics
NPI:1396293890
Name:GUNDERSON, KATHERINE E (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:GUNDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:E
Other - Last Name:MIKKELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-251-6100
Mailing Address - Fax:608-260-2976
Practice Address - Street 1:3400 DEERFIELD DR
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-3557
Practice Address - Country:US
Practice Address - Phone:608-314-3600
Practice Address - Fax:608-314-3601
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3892-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1396293890Medicaid