Provider Demographics
NPI:1275706913
Name:JOHNSON, AMBER RENEE (PAC MMS)
Entity Type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:RENEE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC MMS
Other - Prefix:MS
Other - First Name:AMBER
Other - Middle Name:RENEE
Other - Last Name:STRUBHAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MMS PAC
Mailing Address - Street 1:12255 DE PAUL DR
Mailing Address - Street 2:SUITE 460
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2510
Mailing Address - Country:US
Mailing Address - Phone:314-770-1844
Mailing Address - Fax:314-770-1843
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:SUITE 460
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-770-1844
Practice Address - Fax:314-770-1843
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008026707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant