Provider Demographics
NPI:1255878237
Name:LEVIN, JONATHAN A
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
Last Name:LEVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-7707
Mailing Address - Country:US
Mailing Address - Phone:314-283-9735
Mailing Address - Fax:
Practice Address - Street 1:425 PINE RIDGE BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4123
Practice Address - Country:US
Practice Address - Phone:715-845-5505
Practice Address - Fax:715-848-2884
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI233392-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered