Provider Demographics
NPI:1568777423
Name:JOHNSON, NATASHA L (RPA-C)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8510 BALBOA BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-5810
Mailing Address - Country:US
Mailing Address - Phone:818-637-2000
Mailing Address - Fax:818-654-3417
Practice Address - Street 1:126 SPANISH TRL APT F
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14612-4613
Practice Address - Country:US
Practice Address - Phone:607-661-5418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014190363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03261218Medicaid
NYJ400042818/BA0017GRPMedicare PIN
NYJ400027006/70008AGRPMedicare PIN