Provider Demographics
NPI:1336322205
Name:JOHNSON, KENYA B (PA)
Entity Type:Individual
Prefix:MRS
First Name:KENYA
Middle Name:B
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 1:590 MEDICAL PARK DR.
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:NC
Mailing Address - Zip Code:28753-6807
Mailing Address - Country:US
Mailing Address - Phone:828-689-3507
Mailing Address - Fax:828-689-3505
Practice Address - Street 1:590 MEDICAL PARK DR.
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:NC
Practice Address - Zip Code:28753-6807
Practice Address - Country:US
Practice Address - Phone:828-689-3507
Practice Address - Fax:828-689-3505
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103981363A00000X
NC363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2761110AMedicare PIN