Provider Demographics
NPI:1003164575
Name:JOHNSON, KAREN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
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 1:9290 N CORAL REEF RD
Mailing Address - Street 2:
Mailing Address - City:MC CORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46055-9241
Mailing Address - Country:US
Mailing Address - Phone:317-336-1797
Mailing Address - Fax:
Practice Address - Street 1:7575 E 30TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1112
Practice Address - Country:US
Practice Address - Phone:317-803-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000367A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant