Healthcare Provider Details

I. General information

NPI: 1053195099
Provider Name (Legal Business Name): KRISTIAN ANDERSON AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E INDUSTRIAL DR UNIT 627
HARTLAND WI
53029-0820
US

IV. Provider business mailing address

3581 S 51ST ST
GREENFIELD WI
53220-1545
US

V. Phone/Fax

Practice location:
  • Phone: 414-850-7586
  • Fax:
Mailing address:
  • Phone: 715-370-1691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number241106-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number14649-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: