Provider Demographics
NPI:1972667749
Name:JOHNSON, SUSAN MCCAMBLY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:MCCAMBLY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MCCAMBLY
Other - Last Name:FLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN FORMERLY
Mailing Address - Street 1:2750 GREENSCREEK CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516
Mailing Address - Country:US
Mailing Address - Phone:907-522-0167
Mailing Address - Fax:907-646-2573
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:STE. 322
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5222
Practice Address - Country:US
Practice Address - Phone:907-562-1234
Practice Address - Fax:907-561-8550
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK531OtherSTATELIC
AK531OtherSTATELIC
AKMJ0632206OtherDEA