Healthcare Provider Details

I. General information

NPI: 1992944904
Provider Name (Legal Business Name): MARY ELIZABETH KING JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2009
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 N MASON RD SUITE 103
SAINT LOUIS MO
63141-6399
US

IV. Provider business mailing address

1352 CULPEPPER RIDGE DR
BALLWIN MO
63021-7527
US

V. Phone/Fax

Practice location:
  • Phone: 314-469-7246
  • Fax:
Mailing address:
  • Phone: 972-898-9221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085003419
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2009001275
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: