Provider Demographics
NPI:1295700524
Name:MATHESON, BRITTNEY A (PAC)
Entity type:Individual
Prefix:
First Name:BRITTNEY
Middle Name:A
Last Name:MATHESON
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 1:400 STINSON BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1687 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54022-1571
Practice Address - Country:US
Practice Address - Phone:715-425-6701
Practice Address - Fax:715-426-3994
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295700524Medicaid
MN786088900Medicaid
MN786088900Medicaid
MN970002448Medicare ID - Type Unspecified