Provider Demographics
NPI:1194126607
Name:JOHNSON, ABIGAIL RUTH (PA)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:RUTH
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 1:5010 STATE HIGHWAY 30 STE 205
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-7532
Mailing Address - Country:US
Mailing Address - Phone:518-842-2663
Mailing Address - Fax:518-842-4861
Practice Address - Street 1:5010 STATE HIGHWAY 30 STE 205
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-842-2663
Practice Address - Fax:518-842-4861
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid
NYPENDINGMedicaid