Provider Demographics
NPI:1174024780
Name:JOHNSON WADE, MILAN (CPNP)
Entity Type:Individual
Prefix:
First Name:MILAN
Middle Name:
Last Name:JOHNSON WADE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-0307
Mailing Address - Country:US
Mailing Address - Phone:770-887-1668
Mailing Address - Fax:770-781-9937
Practice Address - Street 1:5959 HIGHWAY 53 E STE 100
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6288
Practice Address - Country:US
Practice Address - Phone:706-381-6125
Practice Address - Fax:706-531-0075
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN234027363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003202448AMedicaid