Provider Demographics
NPI:1427429620
Name:JOHNSON, HANNAH (PA-C)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:4359 NEW SHEPHERDSVILLE RD UNIT 245
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-8004
Practice Address - Country:US
Practice Address - Phone:502-350-5492
Practice Address - Fax:502-350-5822
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC438363AS0400X
KYPA2044363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100386810Medicaid
KYK196390Medicare PIN