Provider Demographics
NPI:1902852072
Name:MATTISON, ANDREA M (PAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:M
Last Name:MATTISON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 MARKET LN
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-3430
Mailing Address - Country:US
Mailing Address - Phone:262-551-4600
Mailing Address - Fax:262-551-4630
Practice Address - Street 1:3400 MARKET LN
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-3430
Practice Address - Country:US
Practice Address - Phone:262-551-4600
Practice Address - Fax:262-551-4630
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1391363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41928000Medicaid
WI008032250Medicare PIN
P33764Medicare UPIN