Healthcare Provider Details

I. General information

NPI: 1639173529
Provider Name (Legal Business Name): JOHNNA JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MAIN ST
CONCORD GA
30206-5504
US

IV. Provider business mailing address

60 MAIN ST
CONCORD GA
30206-5504
US

V. Phone/Fax

Practice location:
  • Phone: 678-786-2724
  • Fax: 770-588-0910
Mailing address:
  • Phone: 678-786-2724
  • Fax: 770-588-0910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number00456
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: