Healthcare Provider Details

I. General information

NPI: 1861056269
Provider Name (Legal Business Name): HEATHER JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 04/10/2021
Certification Date: 04/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 NW 22ND AVE STE 110
PORTLAND OR
97210-2934
US

IV. Provider business mailing address

716 STEVENS AVE
PORTLAND ME
04103-2656
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-8654
  • Fax: 503-413-8655
Mailing address:
  • Phone: 207-283-0171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA201551
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: