Healthcare Provider Details

I. General information

NPI: 1437380144
Provider Name (Legal Business Name): ADRIAN M JOHNSON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADRIAN CLEAVENGER

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 ATLEE RD
MECHANICSVILLE VA
23116-1844
US

IV. Provider business mailing address

38935 ANN ARBOR RD CREDENTIALING DEPT FOR OHM
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 804-764-6300
  • Fax: 804-764-6562
Mailing address:
  • Phone: 248-237-3226
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110003024
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: