Provider Demographics
NPI:1003067984
Name:JOHNSON, ANNIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
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:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-0068
Mailing Address - Country:US
Mailing Address - Phone:208-922-5130
Mailing Address - Fax:208-922-5132
Practice Address - Street 1:708 E WYTHE CREEK CT STE 103
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5005
Practice Address - Country:US
Practice Address - Phone:208-922-5130
Practice Address - Fax:208-922-5132
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-777363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical