Provider Demographics
NPI:1164514618
Name:JOHNSON, PATRICIA ANN (PA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ANN
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6320 W UNION HILLS DR STE 1800
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1372
Mailing Address - Country:US
Mailing Address - Phone:480-372-2117
Mailing Address - Fax:480-372-2118
Practice Address - Street 1:4503 BROOKPARK RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1009
Practice Address - Country:US
Practice Address - Phone:216-398-0349
Practice Address - Fax:216-398-0529
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7473363AS0400X
OH50.002347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGRPA31461Medicare PIN