Provider Demographics
NPI:1114030566
Name:JOHNSON, DELISHA M (PAC)
Entity Type:Individual
Prefix:
First Name:DELISHA
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:DELISHA
Other - Middle Name:
Other - Last Name:DURHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337
Mailing Address - Country:US
Mailing Address - Phone:360-478-2366
Mailing Address - Fax:360-373-2096
Practice Address - Street 1:320 S KITSAP BLVD
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3778
Practice Address - Country:US
Practice Address - Phone:360-876-7215
Practice Address - Fax:360-876-6721
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004048363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8321150Medicaid
WA8321150Medicaid