Provider Demographics
NPI:1851538383
Name:JOHNSON, MARLA GEDDIS (PA)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:GEDDIS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HAWTHORNE PARK CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3194
Mailing Address - Country:US
Mailing Address - Phone:864-603-5600
Mailing Address - Fax:864-603-5601
Practice Address - Street 1:406 MEMORIAL DRIVE EXT
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1818
Practice Address - Country:US
Practice Address - Phone:864-877-9066
Practice Address - Fax:864-848-3291
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0745PAMedicaid
SCP00713097OtherRR MEDICARE
SCAA34507951Medicare PIN
SCAA34506634Medicare PIN
SC0745PAMedicaid