Healthcare Provider Details

I. General information

NPI: 1174933089
Provider Name (Legal Business Name): ANDREW LAU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10625 W NORTH AVE STE 102
MILWAUKEE WI
53226-2315
US

IV. Provider business mailing address

10625 W NORTH AVE STE 102
MILWAUKEE WI
53226-2315
US

V. Phone/Fax

Practice location:
  • Phone: 414-877-5350
  • Fax: 414-877-5360
Mailing address:
  • Phone: 414-877-5350
  • Fax: 414-877-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number67571-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: