Provider Demographics
NPI:1578098695
Name:JOHNSON, PRISCILLA PHAN (PA)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:PHAN
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 11037
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32524-1037
Mailing Address - Country:US
Mailing Address - Phone:850-444-7000
Mailing Address - Fax:850-444-7497
Practice Address - Street 1:1100 W LAKE COMMONS DR
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-7932
Practice Address - Country:US
Practice Address - Phone:706-250-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11803207Q00000X, 363A00000X
FLPA9110351363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020947500Medicaid
FLPA9110351OtherFLORIDA STATE DOH MEDICAL LICENSURE