Provider Demographics
NPI:1295877785
Name:JOHNSON, LISA MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
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 1:150 5TH AVE STE A
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3154
Mailing Address - Country:US
Mailing Address - Phone:321-254-6803
Mailing Address - Fax:321-254-6819
Practice Address - Street 1:150 5TH AVE STE A
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3154
Practice Address - Country:US
Practice Address - Phone:321-254-6803
Practice Address - Fax:321-254-6819
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1338363AM0700X
FLPA9108416363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200028010AMedicaid
OK200028010AMedicaid