Provider Demographics
NPI:1326081316
Name:JOHNSON, THERESE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:ANN
Last Name:JOHNSON
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 1:6053 N SHORELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4662
Mailing Address - Country:US
Mailing Address - Phone:414-962-0945
Mailing Address - Fax:
Practice Address - Street 1:3267 S 16TH STREET
Practice Address - Street 2:EMS OFFICE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-647-5203
Practice Address - Fax:414-647-5203
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI674-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI674-023OtherWISCONSIN STATE LICENSE
WI559923Medicare UPIN