Provider Demographics
NPI:1437554425
Name:JOHNSON, LORI A (PA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7326
Practice Address - Country:US
Practice Address - Phone:843-212-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2171363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2171OtherSC LICENSE
SCSC48247555Medicare PIN
SCSC48248798Medicare PIN
SCSC48247126Medicare PIN
SCSC48247819Medicare PIN
SCSC48247499Medicare PIN
SCSC48246868Medicare PIN
SCSC48247498Medicare PIN
SCSC48245281Medicare PIN
SCSC48245277Medicare PIN
SCSC48245282Medicare UPIN
SC2046PAMedicaid
SCSC48246834Medicare PIN
SCSC48247006Medicare PIN
SCSC48247522Medicare PIN