Provider Demographics
NPI:1033218581
Name:JOHNSON, CHARLA V (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHARLA
Other - Middle Name:V
Other - Last Name:SHELBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:950 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 212
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:404-307-3062
Mailing Address - Fax:
Practice Address - Street 1:950 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 212
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7343
Practice Address - Country:US
Practice Address - Phone:404-307-3062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003556363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA667084523BMedicaid
GA667084523BMedicaid
GA97WCGBQMedicare PIN