Provider Demographics
NPI:1730413709
Name:JOHANSON, LEIGH VAINIO
Entity type:Individual
Prefix:MRS
First Name:LEIGH
Middle Name:VAINIO
Last Name:JOHANSON
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 1:32 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORT
Mailing Address - State:NC
Mailing Address - Zip Code:28762-0017
Mailing Address - Country:US
Mailing Address - Phone:828-659-5741
Mailing Address - Fax:828-668-0015
Practice Address - Street 1:32 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORT
Practice Address - State:NC
Practice Address - Zip Code:28762-0017
Practice Address - Country:US
Practice Address - Phone:828-659-5714
Practice Address - Fax:828-668-0015
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC013338363AM0700X
NC0010-02120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2762269Medicare PIN