Provider Demographics
NPI:1417955394
Name:JOHANNES, JULIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:JOHANNES
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 1:3515 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-4934
Mailing Address - Country:US
Mailing Address - Phone:919-781-5600
Mailing Address - Fax:919-782-6578
Practice Address - Street 1:2455 EMERALD PL
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5785
Practice Address - Country:US
Practice Address - Phone:252-758-2224
Practice Address - Fax:252-758-2860
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S90638Medicare UPIN