MEDICARE: CARLA D JOHNSON PA

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	002753	GA

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	:	1578626412
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA D JOHNSON PA

Provider Business Mailing Address
First Line	:	101 OAKLAND CROSSING DR
Second Line	:
City	:	LEESBURG
State	:	GA
Zip	:	31763-7228
Country	:	US
Telephone Number	:	229-888-4093
Fax Number	:	229-888-4098

Provider Business Practice Location Address
First Line	:	101 OAKLAND CROSSING DR
Second Line	:
City	:	LEESBURG
State	:	GA
Zip	:	31763-7228
Country	:	US
Telephone Number	:	229-888-4093
Fax Number	:	229-888-4098

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

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	04/06/2016

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Directions to “ CARLA D JOHNSON PA” Practice Location

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