Provider Demographics
NPI:1104135052
Name:JOHNSON, STEPHANIE (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:5046 BETSY ROSS WAY
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5933
Mailing Address - Country:US
Mailing Address - Phone:315-956-0900
Mailing Address - Fax:
Practice Address - Street 1:5046 BETSY ROSS WAY
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-5933
Practice Address - Country:US
Practice Address - Phone:315-956-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4777363A00000X
FL9108630363A00000X
NY014259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03537042Medicaid
NY03537042Medicaid