Provider Demographics
NPI:1053325126
Name:JOHNSON, COURTNEY K (PA-C)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:COURTNEY
Other - Middle Name:A
Other - Last Name:KUEHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-9160
Mailing Address - Fax:414-805-9170
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-9160
Practice Address - Fax:414-805-9170
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1583363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053325126Medicaid
WI1053325126Medicaid
WI074T73601Medicare PIN