Provider Demographics
NPI:1730691486
Name:JOHNSTON, DEBORA (PA-C)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DEBORA
Other - Middle Name:
Other - Last Name:FIORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:11 IMPERIAL DR
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-3225
Mailing Address - Country:US
Mailing Address - Phone:631-504-7639
Mailing Address - Fax:
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-4118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant