Provider Demographics
NPI:1679206296
Name:MCCARTHY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MCCARTHY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1389 E STATE ROAD 59
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53563-8929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3401 N PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-8011
Practice Address - Country:US
Practice Address - Phone:815-971-2000
Practice Address - Fax:815-971-9447
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7946-23363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program