Healthcare Provider Details

I. General information

NPI: 1730775933
Provider Name (Legal Business Name): EVAN JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2020
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 E 4TH ST STE 200
SANTA ANA CA
92705-3917
US

IV. Provider business mailing address

3102 JAMESON PASS
ALPHARETTA GA
30022-3028
US

V. Phone/Fax

Practice location:
  • Phone: 888-959-5192
  • Fax:
Mailing address:
  • Phone: 562-677-4396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14256
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: