Provider Demographics
NPI:1811415276
Name:JOHNSON, MEREDITH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3835 ALTA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-4052
Mailing Address - Country:US
Mailing Address - Phone:707-236-2397
Mailing Address - Fax:
Practice Address - Street 1:72 E CONCORD ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2642
Practice Address - Country:US
Practice Address - Phone:707-236-2397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant