Provider Demographics
NPI:1285370874
Name:JOHNSON, SONSERAY D (PBT)
Entity type:Individual
Prefix:MISS
First Name:SONSERAY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 TARGET ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6263
Mailing Address - Country:US
Mailing Address - Phone:843-374-9084
Mailing Address - Fax:
Practice Address - Street 1:7950 CROSSROADS DR APT 113
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9414
Practice Address - Country:US
Practice Address - Phone:888-910-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-07
Last Update Date:2022-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC87-1932845Medicaid