Provider Demographics
NPI:1346208287
Name:JOHNSON, MICHELE L (PA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
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 1:1430 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4626
Mailing Address - Country:US
Mailing Address - Phone:918-748-8024
Mailing Address - Fax:918-748-8249
Practice Address - Street 1:1430 TERRACE DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104
Practice Address - Country:US
Practice Address - Phone:918-748-8024
Practice Address - Fax:918-748-8249
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100187280AMedicaid
OK24H620528Medicare PIN
OK100187280AMedicaid
OKPA007881Medicare PIN
OK24H619022Medicare PIN
OK970018312Medicare PIN
OKR81539Medicare UPIN
OKP00291158Medicare PIN