Provider Demographics
NPI:1336370154
Name:RUSH, JEANNE MAUDLIN (PA)
Entity Type:Individual
Prefix:MRS
First Name:JEANNE
Middle Name:MAUDLIN
Last Name:RUSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JEANNE
Other - Middle Name:ALLISON
Other - Last Name:MAUDLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 387
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003043363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical