Provider Demographics
NPI:1174504385
Name:JOHNSON, AMY (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK STREE
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:13 PALMER AVE
Practice Address - Street 2:EVERGREEN MEDICAL CENTER
Practice Address - City:CORINTH
Practice Address - State:NY
Practice Address - Zip Code:12822-1145
Practice Address - Country:US
Practice Address - Phone:518-654-6499
Practice Address - Fax:518-654-7303
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347657Medicaid
NYP00326248OtherRR MEDICARE
NY02347657Medicaid
NYPA0164Medicare PIN