Provider Demographics
NPI:1952398083
Name:JOHNSON GUESS, SANDRA KAY (PA C)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
Last Name:JOHNSON GUESS
Suffix:
Gender:F
Credentials:PA C
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 7044
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7044
Mailing Address - Country:US
Mailing Address - Phone:270-217-1203
Mailing Address - Fax:
Practice Address - Street 1:2501 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3813
Practice Address - Country:US
Practice Address - Phone:270-217-1203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA 693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004685Medicaid
KY000000313069OtherANTHEM BCBS
P95442Medicare UPIN
KY000000313069OtherANTHEM BCBS