Healthcare Provider Details

I. General information

NPI: 1194003012
Provider Name (Legal Business Name): AMY R JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY LAKE

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY STE 500
SEATTLE WA
98122-4396
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-215-5921
  • Fax: 206-215-5922
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60453895
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60453895
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: