Provider Demographics
NPI:1700939220
Name:JOHNSON, ANDREA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:ANDREA
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 1:350 N COX ST
Mailing Address - Street 2:STE 28
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5514
Mailing Address - Country:US
Mailing Address - Phone:336-629-6500
Mailing Address - Fax:336-629-9500
Practice Address - Street 1:350 N COX ST STE 28
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5514
Practice Address - Country:US
Practice Address - Phone:336-629-6500
Practice Address - Fax:336-629-9500
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NC103798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1700939220Medicaid