MEDICARE: LORI 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	PA3328	FL
2	363A00000X	Physician Assistant	0110004445	VA
3	363A00000X	Physician Assistant	004939-1	NY

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	:	1730591264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI JOHNSON PA-C

Provider Business Mailing Address
First Line	:	3386 LAUREL GRV S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-7816
Country	:	US
Telephone Number	:	904-613-7910
Fax Number	:

Provider Business Practice Location Address
First Line	:	3386 LAUREL GRV S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32223-7816
Country	:	US
Telephone Number	:	904-613-7910
Fax Number	:

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

Provider Enumeration Date	:	06/02/2014
Last Update Date	:	06/02/2014

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Directions to “ LORI JOHNSON PA-C” Practice Location

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