Provider Demographics
NPI:1932297967
Name:JOHNSON, CHERI K (PA-C)
Entity Type:Individual
Prefix:
First Name:CHERI
Middle Name:K
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 1:457 BUCKNER CIR
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36205-4413
Mailing Address - Country:US
Mailing Address - Phone:912-704-7367
Mailing Address - Fax:
Practice Address - Street 1:171 VILLAGE LAKE DR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-2147
Practice Address - Country:US
Practice Address - Phone:912-349-5165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003850363A00000X
ALPA.930363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0980PAMedicaid
GAP00853761OtherRR MEDICARE
GA100002280FMedicaid
582203199-004OtherHMHS TRICARE SOUTH - SAVANNAH
GA100002280GMedicaid
582203199-009OtherHMHS TRICARE SOUTH - POOLER
P50804Medicare UPIN
GA100002280GMedicaid