Provider Demographics
NPI:1336102516
Name:WAATAJA, JOHNNIE (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:
Last Name:WAATAJA
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 1:411 BILLINGSLEY RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1066
Mailing Address - Country:US
Mailing Address - Phone:704-577-3186
Mailing Address - Fax:704-626-2701
Practice Address - Street 1:411 BILLINGSLEY RD STE 103
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1066
Practice Address - Country:US
Practice Address - Phone:704-577-3186
Practice Address - Fax:704-626-2701
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0700PAMedicaid
NC1336102516Medicaid
NC8101209Medicaid
NC1336102516Medicaid
NC8101209Medicaid
SCAA11838397Medicare PIN
SCQ58837Medicare UPIN