Basic Information
| Provider Information | |||||||||
| NPI: | 1093114050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATUSZAK | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP-AC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DOUGHTY | ||||||||
| OtherFirstName: | ALYSSA | ||||||||
| OtherMiddleName: | RAE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CPNP-AC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9000 W. WISCONSIN AVE | ||||||||
| Address2: | MS 681 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663360 | ||||||||
| FaxNumber: | 4142663563 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 W. WISCONSIN AVE | ||||||||
| Address2: | MS 681 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142663360 | ||||||||
| FaxNumber: | 4142663563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2014 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 179985 | WI | N | Nursing Service Providers | Registered Nurse | 363LP0222X | 5928-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 1093114050 | 05 | WI | MEDICAID |