Provider Demographics
NPI:1992137012
Name:BURGESS, LINDSEY JO PROVENZANO (PA-C)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:JO PROVENZANO
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LINDSEY
Other - Middle Name:JO
Other - Last Name:PROVENZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:201 E MORRISSEY DR
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-4395
Mailing Address - Country:US
Mailing Address - Phone:262-723-6666
Mailing Address - Fax:
Practice Address - Street 1:201 E MORRISSEY DR
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4395
Practice Address - Country:US
Practice Address - Phone:262-723-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant