Provider Demographics
NPI:1790720266
Name:JOHNSON, SHARON MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHARON
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:MARIE
Other - Last Name:VANTUYL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:419 S CORAL ST
Mailing Address - Street 2:SUITE 225
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-2503
Mailing Address - Country:US
Mailing Address - Phone:231-258-7502
Mailing Address - Fax:231-258-7527
Practice Address - Street 1:419 S CORAL ST
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-2503
Practice Address - Country:US
Practice Address - Phone:231-258-7506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004623363A00000X
NC0010-02848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460309Medicare PIN
NCNC0170CMedicare PIN
MI0M74460298Medicare PIN