=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023210689
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANN JOHNSON P.A.-C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2007
-----------------------------------------------------
Last Update Date | 05/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 875 BLAKE WILBUR DR
-----------------------------------------------------
City | STANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-721-5448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 875 BLAKE WILBUR DRIVE
-----------------------------------------------------
City | STANFORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94305-5826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-721-5448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA 17782
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------