Provider Demographics
NPI:1003819384
Name:JOHNSON, TRICIA A (R-PAC)
Entity Type:Individual
Prefix:MS
First Name:TRICIA
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-2520
Mailing Address - Country:US
Mailing Address - Phone:973-759-9000
Mailing Address - Fax:973-759-2487
Practice Address - Street 1:433 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-2520
Practice Address - Country:US
Practice Address - Phone:973-759-9000
Practice Address - Fax:973-759-2487
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MPOO117100363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ078865A3WMedicare PIN
NJQ16069Medicare UPIN