Provider Demographics
NPI:1659488211
Name:JOHNSON, CHRISTINE L (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:L
Last Name:JOHNSON
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 1:201 N MAYFAIR RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4216
Mailing Address - Country:US
Mailing Address - Phone:414-771-8228
Mailing Address - Fax:414-256-2483
Practice Address - Street 1:201 N MAYFAIR RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4216
Practice Address - Country:US
Practice Address - Phone:414-771-8228
Practice Address - Fax:414-256-2483
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI237-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42926800Medicaid
WIP96285Medicare UPIN