Provider Demographics
NPI: | 1255367322 |
---|---|
Name: | JOHNSON HUGHES, TARA M (PA) |
Entity type: | Individual |
Prefix: | MRS |
First Name: | TARA |
Middle Name: | M |
Last Name: | JOHNSON HUGHES |
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: | PO BOX 13955 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLESTON |
Mailing Address - State: | SC |
Mailing Address - Zip Code: | 29422-3955 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 843-572-8201 |
Mailing Address - Fax: | 843-797-8491 |
Practice Address - Street 1: | 851 LEONARD FULGHUM DR STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | MOUNT PLEASANT |
Practice Address - State: | SC |
Practice Address - Zip Code: | 29464-3793 |
Practice Address - Country: | US |
Practice Address - Phone: | 843-849-1300 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-23 |
Last Update Date: | 2024-12-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SC | A812 | 207Q00000X |
SC | 812 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SC | 2282PA | Medicaid | |
SC | P54170 | Medicare UPIN | |
SC | 2282PA | Medicaid |