Provider Demographics
NPI:1720620479
Name:JOHNSON, EMILY ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ELIZABETH
Other - Last Name:HOSTOTTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:600 IVY ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1627
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2071
Practice Address - Street 1:15 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:NY
Practice Address - Zip Code:14801-1140
Practice Address - Country:US
Practice Address - Phone:607-359-2291
Practice Address - Fax:607-359-2294
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024215363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05936672Medicaid
PA103756780Medicaid