Provider Demographics
NPI:1992944904
Name:JOHNSON, MARY ELIZABETH KING (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH KING
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1352 CULPEPPER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-7527
Mailing Address - Country:US
Mailing Address - Phone:972-898-9221
Mailing Address - Fax:
Practice Address - Street 1:1040 N MASON RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6399
Practice Address - Country:US
Practice Address - Phone:314-469-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003419363A00000X
MO2009001275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL567730004Medicare PIN