Healthcare Provider Details

I. General information

NPI: 1770766842
Provider Name (Legal Business Name): ELIZABETH JOHNSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 E HERNDON AVE
FRESNO CA
93720-3303
US

IV. Provider business mailing address

1303 E HERNDON AVE STE 850
FRESNO CA
93720-3309
US

V. Phone/Fax

Practice location:
  • Phone: 559-450-2663
  • Fax: 559-450-2724
Mailing address:
  • Phone: 559-450-7242
  • Fax: 559-450-7470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22250
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTL1276
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9105317
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA22250
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: