Provider Demographics
NPI:1205223898
Name:JOHNSON, PETAGAYE TM (CRNA)
Entity type:Individual
Prefix:
First Name:PETAGAYE
Middle Name:TM
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 E CHERYL PKWY UNIT 301
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-7659
Mailing Address - Country:US
Mailing Address - Phone:786-278-2008
Mailing Address - Fax:
Practice Address - Street 1:5150 E CHERYL PKWY UNIT 301
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-7659
Practice Address - Country:US
Practice Address - Phone:786-278-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-21
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI222148367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered