Provider Demographics
NPI:1295156768
Name:JOHNSON, MADDIE (PA-C)
Entity type:Individual
Prefix:
First Name:MADDIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MADDIE
Other - Middle Name:
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6010
Mailing Address - Country:US
Mailing Address - Phone:406-731-8888
Mailing Address - Fax:406-731-8318
Practice Address - Street 1:1401 25TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5183
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT587363AM0700X
WYTL587363AM0700X
WYPA587363AM0700X
MT68225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical