Provider Demographics
NPI:1336514645
Name:JOHNSTON, SAMANTHA (PA-C)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1090 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3700
Mailing Address - Country:US
Mailing Address - Phone:928-583-1000
Mailing Address - Fax:866-323-8458
Practice Address - Street 1:51 S BRIAN MICKELSEN PKWY
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3610
Practice Address - Country:US
Practice Address - Phone:928-639-8132
Practice Address - Fax:866-279-8919
Is Sole Proprietor?:No
Enumeration Date:2015-12-11
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6297363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ090822Medicaid
AZZ184390Medicare PIN