Provider Demographics
NPI:1275844664
Name:JOHNSON, DENISE WAYNETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:WAYNETTE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SOUTH 4TH
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601
Mailing Address - Country:US
Mailing Address - Phone:580-331-2296
Mailing Address - Fax:580-331-2267
Practice Address - Street 1:1701 SOUTH 4TH
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601
Practice Address - Country:US
Practice Address - Phone:580-331-2200
Practice Address - Fax:580-331-2239
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1898363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical