Provider Demographics
NPI:1437415064
Name:JOHNSTON, CARMEN (PA)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:JOHNSTON
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 1:315 W OLD KEY DR
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-9057
Mailing Address - Country:US
Mailing Address - Phone:765-475-6963
Mailing Address - Fax:
Practice Address - Street 1:1500 PROVIDENT DR STE A
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46580-3297
Practice Address - Country:US
Practice Address - Phone:574-372-7637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001237A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant