Healthcare Provider Details

I. General information

NPI: 1417262528
Provider Name (Legal Business Name): NANCY MOE JOHNSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 E HUEBBE PKWY BELOIT CLINIC
BELOIT WI
53511-1842
US

IV. Provider business mailing address

1905 E HUEBBE PKWY BELOIT HEALTH SYSTEM INC
BELOIT WI
53511-1842
US

V. Phone/Fax

Practice location:
  • Phone: 608-364-1460
  • Fax: 608-363-7317
Mailing address:
  • Phone: 608-364-2293
  • Fax: 608-364-5452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3203
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2640-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: