Healthcare Provider Details

I. General information

NPI: 1053081000
Provider Name (Legal Business Name): MATTHEW ALAN BAERTLEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 608-397-4165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7851-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: