Provider Demographics
NPI:1265661425
Name:JOHNSON, LAURA TAYLOR (PAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:TAYLOR
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 HAMPSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:MENDHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07945-2003
Mailing Address - Country:US
Mailing Address - Phone:908-812-8781
Mailing Address - Fax:
Practice Address - Street 1:865 STONE ST
Practice Address - Street 2:
Practice Address - City:RAHWAY
Practice Address - State:NJ
Practice Address - Zip Code:07065-2742
Practice Address - Country:US
Practice Address - Phone:732-680-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-09
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00219300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant