Provider Demographics
NPI:1386677649
Name:SWINEHART, JODY W (PA)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:W
Last Name:SWINEHART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20611 WATERTOWN RD STE J
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1871
Mailing Address - Country:US
Mailing Address - Phone:262-928-5900
Mailing Address - Fax:
Practice Address - Street 1:20611 WATERTOWN RD STE J
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1871
Practice Address - Country:US
Practice Address - Phone:262-928-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1304-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42993600Medicaid
WIP07806Medicare UPIN