Provider Demographics
NPI:1801087614
Name:JOHNSON, YVONNE M (PA)
Entity type:Individual
Prefix:MS
First Name:YVONNE
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15TH MEDICAL GROUP
Mailing Address - Street 2:755 SCOTT CIRCLE
Mailing Address - City:HICKAM AFB
Mailing Address - State:HI
Mailing Address - Zip Code:96853-5399
Mailing Address - Country:US
Mailing Address - Phone:808-448-6211
Mailing Address - Fax:808-448-6356
Practice Address - Street 1:15TH MEDICAL GROUP
Practice Address - Street 2:755 SCOTT CIRCLE
Practice Address - City:HICKAM AFB
Practice Address - State:HI
Practice Address - Zip Code:96853-5399
Practice Address - Country:US
Practice Address - Phone:808-448-6211
Practice Address - Fax:808-448-6356
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD271363A00000X
MI5601005071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP1573008Medicare PIN