Provider Demographics
NPI:1114007424
Name:BRIDGES, JOHNNA JOHNSON (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNNA
Middle Name:JOHNSON
Last Name:BRIDGES
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 1:2412 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2567
Mailing Address - Country:US
Mailing Address - Phone:229-244-1400
Mailing Address - Fax:229-244-5512
Practice Address - Street 1:3294 N OAK STREET EXTENSION
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605
Practice Address - Country:US
Practice Address - Phone:229-241-1188
Practice Address - Fax:229-245-7106
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4849208800000X, 363A00000X
GA004849 - PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA866511489AMedicaid
GAQ72085Medicare UPIN