Provider Demographics
NPI:1821481433
Name:VIDIC, ANA (APRN)
Entity Type:Individual
Prefix:
First Name:ANA
Middle Name:
Last Name:VIDIC
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANA
Other - Middle Name:
Other - Last Name:KISIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6830
Mailing Address - Fax:414-955-6214
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6830
Practice Address - Fax:414-955-6214
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH073339-23363L00000X
WI6267363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1821481433Medicaid
NH3105977Medicaid