Provider Demographics
NPI:1902051386
Name:JOHNSON, MEGAN O'DELL
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:O'DELL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2551 GREENWOOD RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3981
Mailing Address - Country:US
Mailing Address - Phone:318-212-8710
Mailing Address - Fax:318-212-8699
Practice Address - Street 1:2551 GREENWOOD RD
Practice Address - Street 2:SUITE 350
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3981
Practice Address - Country:US
Practice Address - Phone:318-212-8710
Practice Address - Fax:318-212-8699
Is Sole Proprietor?:No
Enumeration Date:2008-11-26
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200246363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant