Provider Demographics
NPI:1770766842
Name:JOHNSON, ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:1303 E HERNDON AVE STE 850
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3309
Mailing Address - Country:US
Mailing Address - Phone:559-450-7242
Mailing Address - Fax:559-450-7470
Practice Address - Street 1:1510 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3303
Practice Address - Country:US
Practice Address - Phone:559-450-2663
Practice Address - Fax:559-450-2724
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22250363A00000X, 363AS0400X
SCTL1276363A00000X
FLPA9105317363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant