Provider Demographics
NPI:1093969594
Name:JOHNSON-WHITLOCK, TYONNA L (RPA-C)
Entity Type:Individual
Prefix:
First Name:TYONNA
Middle Name:L
Last Name:JOHNSON-WHITLOCK
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2911
Mailing Address - Country:US
Mailing Address - Phone:315-425-1431
Mailing Address - Fax:
Practice Address - Street 1:819 S SALINA ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3527
Practice Address - Country:US
Practice Address - Phone:315-476-7921
Practice Address - Fax:315-475-1448
Is Sole Proprietor?:No
Enumeration Date:2008-11-11
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012993363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02300012993Medicaid
NYJ400002049Medicare PIN