Provider Demographics
NPI:1063468890
Name:JOHNSON, TAIRY ADAMS (PA-C)
Entity Type:Individual
Prefix:
First Name:TAIRY
Middle Name:ADAMS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TAIRY
Other - Middle Name:ELAINE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2300 OPITZ BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3311
Mailing Address - Country:US
Mailing Address - Phone:703-523-1504
Mailing Address - Fax:
Practice Address - Street 1:2300 OPITZ BLVD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-3311
Practice Address - Country:US
Practice Address - Phone:703-523-1504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001991363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010209838Medicaid
VA010209889Medicaid
VA010209862Medicaid