Individual
ANDREA JO POULSON-PORT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
4100 DEWEY ST, MANITOWOC, WI 54220-5497
(920) 686-5700
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
56118-20
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100024879
—
WI
Enumeration date
04/01/2009
Last updated
09/24/2024
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