Basic Information
| Provider Information | |||||||||
| NPI: | 1598042616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MAUREEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7258 | ||||||||
| Address2: | |||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317937258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542709246 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 TIFT AVE N | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293825554 | ||||||||
| FaxNumber: | 2293820530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2011 | ||||||||
| LastUpdateDate: | 12/14/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 2219 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.