Provider Demographics
NPI:1407945918
Name:WURNIG-JOHNSON, LISA BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
Last Name:WURNIG-JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:KAUTZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-2876
Mailing Address - Fax:605-622-2804
Practice Address - Street 1:815 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4602
Practice Address - Country:US
Practice Address - Phone:605-622-5123
Practice Address - Fax:605-622-5906
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0480363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical