Provider Demographics
NPI:1043732043
Name:CROUSE, JOANNA KELLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:KELLEY
Last Name:CROUSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S SUNNY SLOPE RD STE 136
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4858
Mailing Address - Country:US
Mailing Address - Phone:262-641-6089
Mailing Address - Fax:262-786-4552
Practice Address - Street 1:150 S SUNNY SLOPE RD STE 136
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4858
Practice Address - Country:US
Practice Address - Phone:262-786-4550
Practice Address - Fax:262-786-4552
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4061-23363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043732043Medicaid