Provider Demographics
NPI:1285693770
Name:JOHNSON, STEPHANIE DIANE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:DIANE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:DIANE
Other - Last Name:STAPLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS RD
Practice Address - Street 2:SUITE 160
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4515
Practice Address - Country:US
Practice Address - Phone:410-583-2777
Practice Address - Fax:410-583-2782
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
472PMedicare PIN
P25476Medicare UPIN
MD149619Medicare PIN
6000190001Medicare NSC
MD945LMedicare PIN