Provider Demographics
NPI:1285123828
Name:JOHNSON, AMANDA IRENE (DPM)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:IRENE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DPM
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 16008
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15242-0008
Mailing Address - Country:US
Mailing Address - Phone:412-929-0254
Mailing Address - Fax:412-920-5861
Practice Address - Street 1:647 N BROAD STREET EXT STE 204
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-4604
Practice Address - Country:US
Practice Address - Phone:724-458-6245
Practice Address - Fax:724-458-6244
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PASC007161213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program