Healthcare Provider Details

I. General information

NPI: 1245609510
Provider Name (Legal Business Name): LUKE JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 S STOUGHTON RD
MADISON WI
53716-2257
US

IV. Provider business mailing address

1808 W BELTLINE HWY
MADISON WI
53713-2334
US

V. Phone/Fax

Practice location:
  • Phone: 608-260-6000
  • Fax: 608-260-6161
Mailing address:
  • Phone: 608-250-1497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3536
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: