Provider Demographics
NPI:1821254863
Name:JOHN, AMY JOANN (PAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JOANN
Last Name:JOHN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:1225 S GEAR AVE STE 252
Practice Address - Street 2:
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1687
Practice Address - Country:US
Practice Address - Phone:319-752-1805
Practice Address - Fax:319-752-1629
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA001946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant