Basic Information
| Provider Information | |||||||||
| NPI: | 1851538383 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | GEDDIS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 HAWTHORNE PARK CT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296153194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646035600 | ||||||||
| FaxNumber: | 8646035601 | ||||||||
| Practice Location | |||||||||
| Address1: | 406 MEMORIAL DRIVE EXT | ||||||||
| Address2: | |||||||||
| City: | GREER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296511818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648779066 | ||||||||
| FaxNumber: | 8648483291 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2009 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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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 | 363A00000X | 1394 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0745PA | 05 | SC | MEDICAID | P00713097 | 01 | SC | RR MEDICARE | OTHER |