Provider Demographics
NPI:1467410902
Name:KEES JOHNSON, SUSAN (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KEES 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 1:251 E COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9619
Mailing Address - Country:US
Mailing Address - Phone:608-839-3515
Mailing Address - Fax:
Practice Address - Street 1:251 E COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9619
Practice Address - Country:US
Practice Address - Phone:608-839-3515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI707-023363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7217OtherDEAN HEALTH INSURANCE
WI543400539Medicare PIN
WI058474150Medicare PIN
WI080144447Medicare PIN