Provider Demographics
NPI:1114038700
Name:KILLIAN, JOHANNA ELAINE (PA)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:ELAINE
Last Name:KILLIAN
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 1:300 E MAIDEN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8516
Mailing Address - Country:US
Mailing Address - Phone:269-429-7546
Mailing Address - Fax:269-429-0807
Practice Address - Street 1:300 E MAIDEN LN
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8516
Practice Address - Country:US
Practice Address - Phone:269-429-7546
Practice Address - Fax:269-429-0807
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003414363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1531892018OtherGROUP NPI
MI0A10115OtherBCBSM GROUP
MICG9582OtherPALMETTO GBA GROUP
MIP48324Medicare UPIN
MI1531892018OtherGROUP NPI