Provider Demographics
NPI:1730278771
Name:JOHNSON, GLORIA J (PA-C)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
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:PO BOX 1072
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78294-1072
Mailing Address - Country:US
Mailing Address - Phone:210-614-3355
Mailing Address - Fax:210-614-0530
Practice Address - Street 1:7810 LOUIS PASTEUR DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3471
Practice Address - Country:US
Practice Address - Phone:210-614-3355
Practice Address - Fax:210-614-0530
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 02773363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87N472Medicare PIN