Provider Demographics
NPI:1801811997
Name:JOHNSON, KWENDA KIKORA (PA)
Entity type:Individual
Prefix:MISS
First Name:KWENDA
Middle Name:KIKORA
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:PO BOX 2723
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27802-2723
Mailing Address - Country:US
Mailing Address - Phone:252-212-3486
Mailing Address - Fax:252-212-3497
Practice Address - Street 1:111 S FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-6971
Practice Address - Country:US
Practice Address - Phone:252-446-3333
Practice Address - Fax:252-446-0426
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00351363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0399PAMedicaid
NCQ73022Medicare UPIN
NC2767086Medicare ID - Type UnspecifiedEASTRIDGE FAMILY MEDICINE