Provider Demographics
NPI:1356739015
Name:JOHNSON, KADDIJATOU SANYANG (PA-C, MMS)
Entity type:Individual
Prefix:
First Name:KADDIJATOU
Middle Name:SANYANG
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:KADDIJATOU
Other - Middle Name:
Other - Last Name:SANYANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C, MMS
Mailing Address - Street 1:5221 PARAMOUNT PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5490
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10208 CERNY ST STE 110
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7885
Practice Address - Country:US
Practice Address - Phone:984-215-4590
Practice Address - Fax:984-215-4591
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05462363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMS3419454OtherDEA
NCNCS006AMedicare PIN