Provider Demographics
NPI:1093114050
Name:MATUSZAK, ALYSSA RAE (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:RAE
Last Name:MATUSZAK
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:RAE
Other - Last Name:DOUGHTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-AC
Mailing Address - Street 1:9000 W. WISCONSIN AVE
Mailing Address - Street 2:MS 681
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226
Mailing Address - Country:US
Mailing Address - Phone:414-266-3360
Mailing Address - Fax:414-266-3563
Practice Address - Street 1:9000 W. WISCONSIN AVE
Practice Address - Street 2:MS 681
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-266-3360
Practice Address - Fax:414-266-3563
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI179985163W00000X
WI5928-33363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1093114050Medicaid
WIK400195740Medicare PIN