Provider Demographics
NPI:1598146177
Name:JOHNSON, TIY (PA-C)
Entity Type:Individual
Prefix:
First Name:TIY
Middle Name:
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 1:5600 NE HOLIDAY DR
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2495
Mailing Address - Country:US
Mailing Address - Phone:816-614-0549
Mailing Address - Fax:
Practice Address - Street 1:40 AUTUMN FERN TRL
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-5155
Practice Address - Country:US
Practice Address - Phone:910-364-0971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5119225200000X
NC0010-14083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant