Provider Demographics
NPI:1124226147
Name:JOHNSON, DENISE SMITH (PA-C)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:SMITH
Last Name:JOHNSON
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 1:5406 INGLEBORO CT
Mailing Address - Street 2:
Mailing Address - City:CAPITOL HEIGHTS
Mailing Address - State:MD
Mailing Address - Zip Code:20743-3047
Mailing Address - Country:US
Mailing Address - Phone:301-735-1792
Mailing Address - Fax:
Practice Address - Street 1:12101 OLD LINE CTR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2552
Practice Address - Country:US
Practice Address - Phone:301-843-2223
Practice Address - Fax:301-705-9720
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002293363A00000X
DCPA30173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant