Healthcare Provider Details

I. General information

NPI: 1114396207
Provider Name (Legal Business Name): JULIE A JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE A SOCIA PA-C

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 CASCADE RD SE
GRAND RAPIDS MI
49546-2149
US

IV. Provider business mailing address

4055 CASCADE RD SE
GRAND RAPIDS MI
49546-2149
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-4410
  • Fax:
Mailing address:
  • Phone: 616-252-4410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC675
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601007514
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2307
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002201A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: