Healthcare Provider Details

I. General information

NPI: 1003819384
Provider Name (Legal Business Name): TRICIA A JOHNSON R-PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MADISON AVE
MORRISTOWN NJ
07960-6136
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-6457
US

V. Phone/Fax

Practice location:
  • Phone: 973-971-7355
  • Fax: 973-290-7495
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MPOO117100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: