Provider Demographics
NPI:1770952442
Name:DETTMAN, ANDREA L (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:DETTMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1911
Mailing Address - Country:US
Mailing Address - Phone:608-250-8000
Mailing Address - Fax:608-252-8268
Practice Address - Street 1:1313 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1911
Practice Address - Country:US
Practice Address - Phone:608-250-8000
Practice Address - Fax:608-252-8268
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3587-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01726831OtherRAILROAD MEDICARE
WI1770952442Medicaid
WIP01726831OtherRAILROAD MEDICARE