Provider Demographics
NPI:1396852844
Name:LAUTERBACH, JEAN A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:A
Last Name:LAUTERBACH
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 1:2239 S 108TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1107
Mailing Address - Country:US
Mailing Address - Phone:414-541-2772
Mailing Address - Fax:414-541-2728
Practice Address - Street 1:2239 S 108TH ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-1107
Practice Address - Country:US
Practice Address - Phone:414-541-2772
Practice Address - Fax:414-541-2728
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI186-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42931100Medicaid
680800101Medicare ID - Type UnspecifiedMEDICARE PROVIDER
WI42931100Medicaid