Provider Demographics
NPI:1366656449
Name:JOHNSON, HEATHER (PA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
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 1:990 W ANN ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6204
Mailing Address - Country:US
Mailing Address - Phone:734-414-1099
Mailing Address - Fax:734-414-1065
Practice Address - Street 1:990 W ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6204
Practice Address - Country:US
Practice Address - Phone:734-414-1099
Practice Address - Fax:734-414-1065
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004334363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004334OtherLICENSE