MEDICARE: TYESHIA JOHNSON

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	PA9112794	FL

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

General Provider Information

NPI Number	:	1528608171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYESHIA JOHNSON

Provider Business Mailing Address
First Line	:	1064 MILDRED DIXON WAY
Second Line	:
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-2939
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5845 WINTER GARDEN VINELAND RD
Second Line	:
City	:	WINDERMERE
State	:	FL
Zip	:	34786-6124
Country	:	US
Telephone Number	:	407-203-1682
Fax Number	:

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

Provider Enumeration Date	:	01/12/2020
Last Update Date	:	11/13/2022

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Directions to “ TYESHIA JOHNSON ” Practice Location

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