Provider Demographics
NPI:1194951756
Name:JOHNSON, SHEENA MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:SHEENA
Middle Name:MARIE
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 1:3040 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12306-2102
Mailing Address - Country:US
Mailing Address - Phone:518-357-2011
Mailing Address - Fax:518-357-2330
Practice Address - Street 1:1044 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12307-1508
Practice Address - Country:US
Practice Address - Phone:518-370-1441
Practice Address - Fax:183-959-4315
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02995513Medicaid
NY02995513Medicaid
NY53099AMedicare PIN
NYJ400314488Medicare PIN