Basic Information
| Provider Information | |||||||||
| NPI: | 1467654673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUERN | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JUERN | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | JOSEPHINE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3000 Q ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 Q ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167333304 | ||||||||
| FaxNumber: | 9167333436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 53008 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207NP0225X | 53008 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207N00000X | C155156 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1467654673 | 05 | WI | MEDICAID |