Healthcare Provider Details

I. General information

NPI: 1629529565
Provider Name (Legal Business Name): HEATHER JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2016
Last Update Date: 10/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 W 56TH ST
NEW YORK NY
10019-3800
US

IV. Provider business mailing address

156 W 56TH ST
NEW YORK NY
10019-3800
US

V. Phone/Fax

Practice location:
  • Phone: 844-337-6362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number020273-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: