Basic Information
| Provider Information | |||||||||
| NPI: | 1902852072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTISON | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 MARKET LN | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531443430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625514600 | ||||||||
| FaxNumber: | 2625514630 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 MARKET LN | ||||||||
| Address2: | |||||||||
| City: | KENOSHA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531443430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625514600 | ||||||||
| FaxNumber: | 2625514630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 09/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1391 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 41928000 | 05 | WI | MEDICAID |