Provider Demographics
NPI:1467730580
Name:FETHERSTON, ANDREA J (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:J
Last Name:FETHERSTON
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF NEPHROLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3100
Mailing Address - Fax:414-259-1145
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF NEPHROLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3100
Practice Address - Fax:414-259-1145
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI165295363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467730580Medicaid
WI68086 1107Medicare PIN
WI73601 2319Medicare PIN