Healthcare Provider Details

I. General information

NPI: 1134366016
Provider Name (Legal Business Name): CHERYL L JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHERYL L DEACON PA-C

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 S BENEVA RD SUITE 306
SARASOTA FL
34232-2476
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-362-8644
  • Fax: 941-954-4440
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9104060
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: