Provider Demographics
NPI:1538638812
Name:SOTO, JOHANA (PA)
Entity Type:Individual
Prefix:MISS
First Name:JOHANA
Middle Name:
Last Name:SOTO
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 1:539 POWER PLANT CIR APT 437
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-4220
Mailing Address - Country:US
Mailing Address - Phone:561-542-8893
Mailing Address - Fax:
Practice Address - Street 1:1200 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1004
Practice Address - Country:US
Practice Address - Phone:336-207-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty