Provider Demographics
NPI:1215043120
Name:JOHNSON, SANDRA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:LYNN
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 1:401 NW H ST
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1625
Mailing Address - Country:US
Mailing Address - Phone:918-967-5032
Mailing Address - Fax:918-967-5032
Practice Address - Street 1:401 NW H ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1625
Practice Address - Country:US
Practice Address - Phone:918-967-5032
Practice Address - Fax:918-967-5032
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1293363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200130700AMedicaid
OKOK100269Medicare PIN