Basic Information
| Provider Information | |||||||||
| NPI: | 1649256686 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTHEWS | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OSTROWSKI | ||||||||
| OtherFirstName: | NANCY | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherCredential: | P.A. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6400 INDUSTRIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | GREENDALE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531292452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144234100 | ||||||||
| FaxNumber: | 4144234134 | ||||||||
| Practice Location | |||||||||
| Address1: | 791 E SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | OCONOMOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530663844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625690251 | ||||||||
| FaxNumber: | 2625690342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 927-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42961000 | 05 | WI | MEDICAID |