Provider Demographics
NPI:1881018588
Name:JOHNSON, KATHERINE S (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:S
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 1:1571 WASHINGTON ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-9304
Mailing Address - Country:US
Mailing Address - Phone:315-405-5484
Mailing Address - Fax:
Practice Address - Street 1:1571 WASHINGTON ST
Practice Address - Street 2:SUITE 104
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9304
Practice Address - Country:US
Practice Address - Phone:315-782-1650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-15
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0173471363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical