Provider Demographics
NPI:1508177163
Name:JOHNSON, MARY ANN NAU (MD)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:NAU
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1264 HAWKS FLIGHT CT
Practice Address - Street 2:SUITE 100
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9348
Practice Address - Country:US
Practice Address - Phone:916-939-8400
Practice Address - Fax:916-933-5013
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA113258207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology