Provider Demographics
NPI:1982181913
Name:MATTEK, COURTNEY LYNN (AGPCNP-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:MATTEK
Suffix:
Gender:F
Credentials:AGPCNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:749 DERESCH ST
Mailing Address - Street 2:
Mailing Address - City:ANTIGO
Mailing Address - State:WI
Mailing Address - Zip Code:54409-1175
Mailing Address - Country:US
Mailing Address - Phone:651-428-6811
Mailing Address - Fax:
Practice Address - Street 1:112 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8509-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner