Healthcare Provider Details

I. General information

NPI: 1205690310
Provider Name (Legal Business Name): ANTHONY JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 SPRUCE ST, GRIDLEY
GRIDLEY CA
95948
US

IV. Provider business mailing address

435 VIRGINIA ST APT A
GRIDLEY CA
95948-3043
US

V. Phone/Fax

Practice location:
  • Phone: 530-846-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: