Healthcare Provider Details

I. General information

NPI: 1467763813
Provider Name (Legal Business Name): MATHEW ANDREW TILSON APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2741 W LAYTON AVE STE 201
MILWAUKEE WI
53221-2600
US

IV. Provider business mailing address

2018 N 114TH ST
WAUWATOSA WI
53226-2214
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-8050
  • Fax:
Mailing address:
  • Phone: 414-839-5795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10069
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number172644-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: