Provider Demographics
NPI:1427755859
Name:JOHNSON, MARIESA L (PA-C)
Entity type:Individual
Prefix:
First Name:MARIESA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD # 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1952
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:468 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1507
Practice Address - Country:US
Practice Address - Phone:313-473-6899
Practice Address - Fax:313-473-1509
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-15
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601011569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant