Provider Demographics
NPI:1003103870
Name:JOHNSON, COURTNEY PARHAM (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:PARHAM
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:NICOLE
Other - Last Name:PARHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:346 PEACHTREE LN SE
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-4388
Mailing Address - Country:US
Mailing Address - Phone:423-838-3407
Mailing Address - Fax:
Practice Address - Street 1:204 PROFESSIONAL CT SE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-7020
Practice Address - Country:US
Practice Address - Phone:706-625-5900
Practice Address - Fax:706-625-6519
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1618655OtherAMERIGROUP
GAMC#003112617A&BMedicaid
GA685703OtherWELLCARE