Provider Demographics
NPI:1437783131
Name:PERINOVIC-JOHNSON, MEGAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PERINOVIC-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 1:3365 S 103RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53227-4161
Mailing Address - Country:US
Mailing Address - Phone:414-607-5280
Mailing Address - Fax:414-607-5288
Practice Address - Street 1:3365 S 103RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-4161
Practice Address - Country:US
Practice Address - Phone:414-607-5280
Practice Address - Fax:414-607-5288
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5401363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437783131Medicaid