Provider Demographics
NPI:1750572913
Name:MATYSIAK, KRISTINE M (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:MATYSIAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:M
Other - Last Name:TREML
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:323 S. 18TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235
Mailing Address - Country:US
Mailing Address - Phone:920-746-0510
Mailing Address - Fax:
Practice Address - Street 1:323 S. 18TH AVENUE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235
Practice Address - Country:US
Practice Address - Phone:920-746-0510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2249-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970002532Medicare UPIN