Healthcare Provider Details

I. General information

NPI: 1730631607
Provider Name (Legal Business Name): VICTORIA ADRIENNE JOHNSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136-6163
US

IV. Provider business mailing address

1035 BELLEVUE AVE STE 500
RICHMOND HEIGHTS MO
63117-1843
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-3581
  • Fax: 314-747-1710
Mailing address:
  • Phone: 314-925-4773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2016028639
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: