Provider Demographics
NPI:1073554523
Name:JOHNSON, IDELLA (PA-C)
Entity Type:Individual
Prefix:
First Name:IDELLA
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 1:1610 TAZEWELL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TAZEWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37879-3600
Mailing Address - Country:US
Mailing Address - Phone:423-626-8393
Mailing Address - Fax:423-626-8749
Practice Address - Street 1:1610 TAZEWELL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37879-3600
Practice Address - Country:US
Practice Address - Phone:423-626-8393
Practice Address - Fax:423-626-8749
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN670363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3669471Medicaid
TN4058153OtherBCBS OF TENNESSEE
TNP01257Medicare UPIN
TN3669471Medicare PIN
TN103I979327Medicare PIN