Provider Demographics
NPI:1154622769
Name:JOHNSON, MIEK C (PA)
Entity type:Individual
Prefix:
First Name:MIEK
Middle Name:C
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 1:3686 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6520
Mailing Address - Country:US
Mailing Address - Phone:706-465-3253
Mailing Address - Fax:706-465-3028
Practice Address - Street 1:1008 ATLANTA HWY
Practice Address - Street 2:TRI-COUNTY HEALTH SYSTEM, INC.
Practice Address - City:WARRENTON
Practice Address - State:GA
Practice Address - Zip Code:30828-0312
Practice Address - Country:US
Practice Address - Phone:706-465-3253
Practice Address - Fax:706-465-3028
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000471809AMedicaid
GA000471809AMedicaid