Provider Demographics
NPI:1073703344
Name:JOHNSON, RANDA S (PA-C)
Entity Type:Individual
Prefix:
First Name:RANDA
Middle Name:S
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 1:353 FAIRMONT BLVD
Mailing Address - Street 2:ATTEN CHRISTIE MSS
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:949 HARMON ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:SD
Practice Address - Zip Code:57785-2452
Practice Address - Country:US
Practice Address - Phone:605-720-2400
Practice Address - Fax:605-720-0338
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
253839OtherMIDLANDS CHOICE
IA01C7OtherJOHN DEERE HEALTH
IAI20750Medicare PIN
SD103482OtherMEDICARE ID
133804OtherHEALTH ALLIANCE
P00436310Medicare PIN
SDS103482Medicare PIN
IA70332OtherWELLMARK BCBS
SD6832370Medicaid