Provider Demographics
NPI:1730591264
Name:JOHNSON, LORI (PA-C)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3386 LAUREL GRV S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7816
Mailing Address - Country:US
Mailing Address - Phone:904-613-7910
Mailing Address - Fax:
Practice Address - Street 1:3386 LAUREL GRV S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7816
Practice Address - Country:US
Practice Address - Phone:904-613-7910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3328363A00000X
VA0110004445363A00000X
NY004939-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant