Basic Information
| Provider Information | |||||||||
| NPI: | 1700801370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSTEN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOFFMANN | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 407 KUMQUAT ST | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 365321246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2515812445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 411 N SECTION ST | ||||||||
| Address2: | |||||||||
| City: | FAIRHOPE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516603470 | ||||||||
| FaxNumber: | 2516603471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-393 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 008087700 | 05 | FL | MEDICAID | 51593935 | 01 | AL | BCBS - 1720 CENTER ST | OTHER | 51593844 | 01 | AL | BCBS - 575 STANTON RD | OTHER |