Provider Demographics
NPI:1083923841
Name:WIXSON-JOHNSON, CANDACE KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:KAY
Last Name:WIXSON-JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:K
Other - Last Name:WIXSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5525 S MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3546
Mailing Address - Country:US
Mailing Address - Phone:517-913-3888
Mailing Address - Fax:517-394-8393
Practice Address - Street 1:5525 S MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-3546
Practice Address - Country:US
Practice Address - Phone:517-913-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant