Provider Demographics
NPI:1568292373
Name:BRELIE, MATTHEW (APNP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BRELIE
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3702 SUSSEX LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53714-2353
Mailing Address - Country:US
Mailing Address - Phone:608-556-8078
Mailing Address - Fax:
Practice Address - Street 1:1700 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-3319
Practice Address - Country:US
Practice Address - Phone:608-355-3800
Practice Address - Fax:608-355-7001
Is Sole Proprietor?:No
Enumeration Date:2024-08-06
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15433-33363L00000X
WI15433-033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568292373Medicaid