Provider Demographics
NPI:1457828238
Name:MISCHKE, KATIE (PA)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:MISCHKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:DEMARAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1333 W 5TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2752
Mailing Address - Country:US
Mailing Address - Phone:307-675-2649
Mailing Address - Fax:307-675-2602
Practice Address - Street 1:1333 W 5TH ST STE 113
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2752
Practice Address - Country:US
Practice Address - Phone:307-675-2633
Practice Address - Fax:307-675-2634
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT1355363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical