Provider Demographics
NPI:1841545902
Name:SERMON, MICHAEL JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:SERMON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 RIVER PL
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-4034
Mailing Address - Country:US
Mailing Address - Phone:608-233-2378
Mailing Address - Fax:208-233-2375
Practice Address - Street 1:606 RIVER PL
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-4034
Practice Address - Country:US
Practice Address - Phone:608-233-2378
Practice Address - Fax:608-233-2375
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1764363A00000X
363A00000X
WI8231-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR263650YMDVMedicaid