Provider Demographics
NPI:1962553628
Name:JOHNSON, IVY M (PA-C)
Entity type:Individual
Prefix:MS
First Name:IVY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:IVY
Other - Middle Name:MELISSA
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2720 N HARBOR BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2626
Mailing Address - Country:US
Mailing Address - Phone:714-446-5192
Mailing Address - Fax:714-515-8360
Practice Address - Street 1:2720 N HARBOR BLVD STE 210
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2626
Practice Address - Country:US
Practice Address - Phone:714-446-5192
Practice Address - Fax:714-515-8360
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15987363A00000X
CAPA 15987363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant