Provider Demographics
NPI:1043505092
Name:JOHNSON, KATY FLINN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:FLINN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:
Other - Last Name:FLINN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:910-754-4441
Mailing Address - Fax:910-754-5307
Practice Address - Street 1:5145 SELLERS RD
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3405
Practice Address - Country:US
Practice Address - Phone:910-754-4441
Practice Address - Fax:910-754-5307
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL1657363A00000X
SC1657363A00000X
NC0010-02891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL1657OtherMEDICAL LICENSE
SC1191PAMedicaid
SCAA70829169Medicare PIN