Healthcare Provider Details

I. General information

NPI: 1437415064
Provider Name (Legal Business Name): CARMEN JOHNSTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PROVIDENT DR STE A
WARSAW IN
46580-3297
US

IV. Provider business mailing address

315 W OLD KEY DR
PERU IN
46970-9057
US

V. Phone/Fax

Practice location:
  • Phone: 574-372-7637
  • Fax:
Mailing address:
  • Phone: 765-475-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001237A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: