Provider Demographics
NPI:1497295984
Name:JOHNSON, AMANDA JO (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:JOHNSON
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 1:8055 COUNTRY PINE DR SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302-9142
Mailing Address - Country:US
Mailing Address - Phone:616-901-0280
Mailing Address - Fax:
Practice Address - Street 1:1541 GULL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1644
Practice Address - Country:US
Practice Address - Phone:269-552-0331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant