Provider Demographics
NPI:1588016141
Name:JOHNSTON, MADISON CORINNE (PA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:CORINNE
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MADISON
Other - Middle Name:CORINNE
Other - Last Name:HANLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:801 W TERRELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-877-3277
Mailing Address - Fax:817-877-3280
Practice Address - Street 1:801 W TERRELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-877-3277
Practice Address - Fax:817-877-3280
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant