Provider Demographics
NPI:1891927513
Name:JOHNSON, KATRINA A (PA)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:A
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-383-0201
Mailing Address - Fax:208-383-1130
Practice Address - Street 1:600 N ROBBINS ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4566
Practice Address - Country:US
Practice Address - Phone:208-383-0201
Practice Address - Fax:208-489-4300
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical