Healthcare Provider Details

I. General information

NPI: 1114412459
Provider Name (Legal Business Name): COURTNEY LOIS JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COURTNEY LOIS SIMCOE PA-C

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 TALBOT RD S STE 500
RENTON WA
98055-5782
US

IV. Provider business mailing address

3600 LIND AVE SW STE 100
RENTON WA
98057-4970
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3482
  • Fax: 425-690-9082
Mailing address:
  • Phone: 425-690-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60879450
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: