Basic Information
Provider Information | |||||||||
NPI: | 1982820080 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | KELLI | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRADSHAW | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | KELLI | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1869 | ||||||||
Address2: |   | ||||||||
City: | FLETCHER | ||||||||
State: | NC | ||||||||
PostalCode: | 287321869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286875616 | ||||||||
FaxNumber: | 8286508076 | ||||||||
Practice Location | |||||||||
Address1: | 50 HOSPITAL DR | ||||||||
Address2: | SUITE 2A | ||||||||
City: | HENDERSONVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 287925248 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286546015 | ||||||||
FaxNumber: | 8286876058 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2007 | ||||||||
LastUpdateDate: | 12/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
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 | 363A00000X | 103965 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 103965 | 01 | NC | LICENSE | OTHER | 162EA | 01 | NC | BCBS OF NC | OTHER | P01248091 | 01 | NC | MEDICARE RR | OTHER |