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General NPI Number Information
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NPI Number | 1689211740
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Entity Type | Individual
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Provider Name | GABRIELLE JOHNSON PA-C, ATC
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Gender | Female
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Dates
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Enumeration Date | 12/06/2019
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 9155 SW BARNES RD
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City | PORTLAND
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State | OR
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Zip | 97225-6625
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Country | US
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Telephone | 503-216-1234
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Fax |
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Provider Business Mailing Address
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Address Line | 9155 SW BARNES RD STE 440
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City | PORTLAND
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State | OR
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Zip | 97225-6631
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT-10165263
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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