Provider Demographics
NPI:1801870423
Name:COLE JOHNSON, CHERALAINE E (PA-C)
Entity type:Individual
Prefix:
First Name:CHERALAINE
Middle Name:E
Last Name:COLE 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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N WESTMORELAND RD
Practice Address - Street 2:DEHARO-SALDIVAR HEALTH CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75211-1656
Practice Address - Country:US
Practice Address - Phone:214-266-0500
Practice Address - Fax:214-266-0554
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX060352404Medicaid
TX060352405Medicaid
TX060352402Medicaid
TX8N4452OtherBLUE CROSS BLUE SHIELD
TX060352403Medicaid
TX82N845Medicare PIN
TX060352404Medicaid