Provider Demographics
NPI:1053195099
Name:ANDERSON, KRISTIAN (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3581 S 51ST ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-1545
Mailing Address - Country:US
Mailing Address - Phone:715-370-1691
Mailing Address - Fax:
Practice Address - Street 1:401 E INDUSTRIAL DR UNIT 627
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-0820
Practice Address - Country:US
Practice Address - Phone:414-850-7586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI241106-30163WC0200X
WI14649-33363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine