Healthcare Provider Details

I. General information

NPI: 1497309884
Provider Name (Legal Business Name): ANNALISE M MATHISEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNALISE M KELSEY PA-C

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 LAWRENCE DR STE 103
DE PERE WI
54115-9108
US

IV. Provider business mailing address

1716 LAWRENCE DR STE 103
DE PERE WI
54115-9108
US

V. Phone/Fax

Practice location:
  • Phone: 920-632-6800
  • Fax: 920-632-6806
Mailing address:
  • Phone: 920-632-6800
  • Fax: 920-632-6806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4758-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: