Provider Demographics
NPI:1518252824
Name:MATSON, ANDREA B (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:B
Last Name:MATSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:B
Other - Last Name:HAASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6451
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DEPARTMENT OF EMERGENCY MEDICINE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2755-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1518252824Medicaid
WI1518252824Medicaid
WI68086 1052Medicare PIN