Healthcare Provider Details

I. General information

NPI: 1356739015
Provider Name (Legal Business Name): KADDIJATOU SANYANG JOHNSON PA-C, MMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KADDIJATOU SANYANG PA-C, MMS

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10208 CERNY ST STE 110
RALEIGH NC
27617-7885
US

IV. Provider business mailing address

5221 PARAMOUNT PKWY STE 220
MORRISVILLE NC
27560-5490
US

V. Phone/Fax

Practice location:
  • Phone: 984-215-4590
  • Fax: 984-215-4591
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05462
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: