Provider Demographics
NPI:1437411139
Name:JOHNSON, RON'NISE THERESA (PA)
Entity Type:Individual
Prefix:
First Name:RON'NISE
Middle Name:THERESA
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 1:1250 WATERS PLACE
Mailing Address - Street 2:TOWER II, 7TH FLOOR, VASCULAR SURGERY DEPARTMENT
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461
Mailing Address - Country:US
Mailing Address - Phone:929-263-3741
Mailing Address - Fax:929-263-3948
Practice Address - Street 1:1250 WATERS PLACE
Practice Address - Street 2:TOWER II, 7TH FLOOR, VASCULAR SURGERY DEPARTMENT
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:929-263-3741
Practice Address - Fax:929-263-3948
Is Sole Proprietor?:No
Enumeration Date:2012-06-09
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015529363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical