Provider Demographics
NPI:1881030146
Name:JOHNSON, TENCY R (PA)
Entity Type:Individual
Prefix:MRS
First Name:TENCY
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:TENCY
Other - Middle Name:R
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:100 PORT WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1347
Mailing Address - Country:US
Mailing Address - Phone:516-562-6512
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-563-6215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant