Provider Demographics
NPI:1215187885
Name:JOHNSTON, ANGELA D (PA-C)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3494
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73702-3494
Mailing Address - Country:US
Mailing Address - Phone:580-234-7070
Mailing Address - Fax:580-234-9544
Practice Address - Street 1:3201 N VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-1812
Practice Address - Country:US
Practice Address - Phone:580-234-7070
Practice Address - Fax:580-234-9544
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5249363A00000X
NC0010-08007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1215187885Medicaid