Healthcare Provider Details

I. General information

NPI: 1720309362
Provider Name (Legal Business Name): KIMBERLY ANN JOHNSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KIMBERLY ANN SHAW PA

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD PHYSICIAN EXTENDER
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

750 STEPHENSON HIGHWAY WILLIAM BEAUMONT HOSPITAL PAYOR CONTRACT SERVICES
TROY MI
48083-1103
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-4021
  • Fax: 248-898-1473
Mailing address:
  • Phone: 248-577-3520
  • Fax: 248-577-3526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005757
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: