Basic Information
| Provider Information | |||||||||
| NPI: | 1114007424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRIDGES | ||||||||
| FirstName: | JOHNNA | ||||||||
| MiddleName: | JOHNSON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2412 N OAK ST | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 316022567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292441400 | ||||||||
| FaxNumber: | 2292445512 | ||||||||
| Practice Location | |||||||||
| Address1: | 3294 N OAK STREET EXTENSION | ||||||||
| Address2: | |||||||||
| City: | VALDOSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292411188 | ||||||||
| FaxNumber: | 2292457106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4849 | GA | N | Allopathic & Osteopathic Physicians | Urology | 363A00000X | 004849 - PA | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 4849 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 866511489A | 05 | GA | MEDICAID |