Provider Demographics
NPI:1114412459
Name:JOHNSON, COURTNEY LOIS (PA-C)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LOIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LOIS
Other - Last Name:SIMCOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3600 LIND AVE SW STE 100
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:4011 TALBOT RD S STE 500
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5782
Practice Address - Country:US
Practice Address - Phone:425-690-3482
Practice Address - Fax:425-690-9082
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60879450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant