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NPI Code Detail

MEDICARE: MISS NICOLE MARIE JOHNSON PA-C

MEDICARE: MISS NICOLE MARIE JOHNSON PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant8975784-1206UT

General Provider Information

NPI Number : 1033414248
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS NICOLE MARIE JOHNSON PA-C
Provider Business Mailing Address
First Line : PO BOX 27128
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84127-0128
Country : US
Telephone Number : 801-442-5502
Fax Number :
Provider Business Practice Location Address
First Line : 7302 S BINGHAM JUNCTION BLVD
Second Line :
City : MIDVALE
State : UT
Zip : 84047-4804
Country : US
Telephone Number : 801-442-5502
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/19/2011
Last Update Date : 06/23/2020

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Directions to “ MISS NICOLE MARIE JOHNSON PA-C” Practice Location

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