Provider Demographics
NPI:1851319685
Name:JOHNSON, ANDREA
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SHERMAN ST
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-7080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 SHERMAN ST
Practice Address - Street 2:SUITE 2100
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-7080
Practice Address - Country:US
Practice Address - Phone:716-665-4720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175795207Q00000X
NY175795-01207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01213372Medicaid
NY55892HMedicare ID - Type Unspecified
NY01213372Medicaid
NYE62286Medicare UPIN