Provider Demographics
NPI:1487347928
Name:O'LEARY, JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:O'LEARY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W225N16711 CEDAR PARK CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-9222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W225N16711 CEDAR PARK CT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WI
Practice Address - Zip Code:53037-9222
Practice Address - Country:US
Practice Address - Phone:262-677-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7492-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant