Provider Demographics
NPI:1811146178
Name:JOHNSON, TATIA FORD (MPAS, PA-C)
Entity type:Individual
Prefix:MRS
First Name:TATIA
Middle Name:FORD
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:MISS
Other - First Name:TATIA
Other - Middle Name:LYNN
Other - Last Name:FORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:12150 ANNAPOLIS RD
Mailing Address - Street 2:SUITE #300
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9183
Mailing Address - Country:US
Mailing Address - Phone:301-249-5384
Mailing Address - Fax:301-249-6047
Practice Address - Street 1:12150 ANNAPOLIS RD
Practice Address - Street 2:SUITE #300
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9183
Practice Address - Country:US
Practice Address - Phone:301-249-5384
Practice Address - Fax:301-249-6047
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002501363AM0700X
PAM002916L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP85736Medicare UPIN
MDH888F569Medicare PIN