Basic Information
| Provider Information | |||||||||
| NPI: | 1962755801 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 134 W CHRISFIELD DR | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836463255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412321314 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 N GRAHAM ST STE 125 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972271683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035280704 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2012 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA159647 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.