Provider Demographics
NPI:1386138287
Name:JOHNSON, STEPHEN (AA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 SARA LEE LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-3546
Mailing Address - Country:US
Mailing Address - Phone:850-321-7443
Mailing Address - Fax:850-321-7443
Practice Address - Street 1:2012 SARA LEE LN
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32312-3546
Practice Address - Country:US
Practice Address - Phone:850-321-7443
Practice Address - Fax:850-321-7443
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA468367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist AssistantGroup - Single Specialty