Provider Demographics
NPI:1306928577
Name:JOHNSON, STELIN (PA)
Entity type:Individual
Prefix:
First Name:STELIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 BAINBRIDGE AVE
Mailing Address - Street 2:4TH FLOOR, DEPT OF SURGERY
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2404
Mailing Address - Country:US
Mailing Address - Phone:718-920-4800
Mailing Address - Fax:
Practice Address - Street 1:256 MASON AVE
Practice Address - Street 2:BUILDING B, 2ND FLOOR
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3408
Practice Address - Country:US
Practice Address - Phone:718-226-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400045471Medicare PIN