Provider Demographics
NPI:1639173529
Name:JOHNSON, JOHNNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNNA
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 1:3708 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2404
Mailing Address - Country:US
Mailing Address - Phone:478-254-5303
Mailing Address - Fax:478-254-5324
Practice Address - Street 1:231 GRAEFE ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4222
Practice Address - Country:US
Practice Address - Phone:770-227-1587
Practice Address - Fax:770-227-1485
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant