Provider Demographics
NPI:1386951465
Name:JOHNSON, MARY ANNE (PAC)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 W LACEY BLVD
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-5906
Mailing Address - Country:US
Mailing Address - Phone:559-583-4617
Mailing Address - Fax:559-583-4625
Practice Address - Street 1:1433 N ACACIA AVE
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654-2102
Practice Address - Country:US
Practice Address - Phone:559-391-3100
Practice Address - Fax:559-637-7550
Is Sole Proprietor?:No
Enumeration Date:2010-09-09
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21162363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical