Basic Information
| Provider Information | |||||||||
| NPI: | 1912498791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CEELEN | ||||||||
| FirstName: | ANDREW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530249201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623291000 | ||||||||
| FaxNumber: | 2623291001 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530249201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623291000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2018 | ||||||||
| LastUpdateDate: | 11/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 8081-033 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1912498791 | 05 | WI | MEDICAID |