Healthcare Provider Details

I. General information

NPI: 1952668816
Provider Name (Legal Business Name): JULIE LEA AUGUSTINE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2012
Last Update Date: 12/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 N 25TH ST
SHEBOYGAN WI
53081-3108
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 920-457-9100
  • Fax: 920-457-1461
Mailing address:
  • Phone: 866-630-9882
  • Fax: 920-683-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number680-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: