Provider Demographics
NPI:1457880510
Name:JOHNSON, AUTUMN LAUREN (MPAP, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:LAUREN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPAP, PA-C
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:LAUREN
Other - Last Name:PURKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:360 GIOTTO
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-8581
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2650 S BRISTOL ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5751
Practice Address - Country:US
Practice Address - Phone:714-754-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2017-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant