Basic Information
| Provider Information | |||||||||
| NPI: | 1003067984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | ANNIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 68 | ||||||||
| Address2: | |||||||||
| City: | KUNA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836340068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089225130 | ||||||||
| FaxNumber: | 2089225132 | ||||||||
| Practice Location | |||||||||
| Address1: | 708 E WYTHE CREEK CT STE 103 | ||||||||
| Address2: | |||||||||
| City: | KUNA | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836345005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2089225130 | ||||||||
| FaxNumber: | 2089225132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2008 | ||||||||
| LastUpdateDate: | 12/01/2010 | ||||||||
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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 | PA-777 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.