Provider Demographics
NPI:1720309362
Name:JOHNSON, KIMBERLY ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:750 STEPHENSON HIGHWAY
Mailing Address - Street 2:WILLIAM BEAUMONT HOSPITAL PAYOR CONTRACT SERVICES
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1103
Mailing Address - Country:US
Mailing Address - Phone:248-577-3520
Mailing Address - Fax:248-577-3526
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:PHYSICIAN EXTENDER
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-4021
Practice Address - Fax:248-898-1473
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant