Provider Demographics
NPI:1750504981
Name:JOHNSON, LAURA (PA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:NICOLE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1111 GLYNCO PKWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-7921
Mailing Address - Country:US
Mailing Address - Phone:912-265-1357
Mailing Address - Fax:912-265-0495
Practice Address - Street 1:1111 GLYNCO PKWY
Practice Address - Street 2:SUITE 400
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-7921
Practice Address - Country:US
Practice Address - Phone:912-265-1357
Practice Address - Fax:912-265-0495
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004660OtherSTATE LICENSE
GAQ58576Medicare UPIN
GA004660OtherSTATE LICENSE