MEDICARE: KAYLA RENEE JOHNSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10002926A	IN
2	363A00000X	Physician Assistant	02657	WV

General Provider Information

NPI Number	:	1578963179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLA RENEE JOHNSON PA-C

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	755 W CARMEL DR STE 101
Second Line	:
City	:	CARMEL
State	:	IN
Zip	:	46032-5875
Country	:	US
Telephone Number	:	317-846-2396
Fax Number	:	317-846-1699

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2014
Last Update Date	:	09/20/2021

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