MEDICARE: SALLY-ANN P JOHANNSEN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3502-23	WI

General Provider Information

NPI Number	:	1639234610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SALLY-ANN P JOHANNSEN PA

Provider Business Mailing Address
First Line	:	717 HIDDEN CAVE RD
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53717-2755
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	717 HIDDEN CAVE RD
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53717-2755
Country	:	US
Telephone Number	:	608-203-5309
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2006
Last Update Date	:	02/05/2020

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