MEDICARE: IDELLA 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
1	363A00000X	Physician Assistant	670	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4058153	OTHER	TN	BCBS OF TENNESSEE

General Provider Information

NPI Number	:	1073554523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IDELLA JOHNSON PA-C

Provider Business Mailing Address
First Line	:	1610 TAZEWELL RD
Second Line	:	SUITE 201
City	:	TAZEWELL
State	:	TN
Zip	:	37879-3600
Country	:	US
Telephone Number	:	423-626-8393
Fax Number	:	423-626-8749

Provider Business Practice Location Address
First Line	:	1610 TAZEWELL RD
Second Line	:	SUITE 201
City	:	TAZEWELL
State	:	TN
Zip	:	37879-3600
Country	:	US
Telephone Number	:	423-626-8393
Fax Number	:	423-626-8749

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	12/16/2015

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Directions to “ IDELLA JOHNSON PA-C” Practice Location

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