Provider Demographics
NPI:1366435166
Name:JOHNSON, CHRISTINA ANN (PAC)
Entity type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PAC
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 337
Mailing Address - Street 2:
Mailing Address - City:SCARBRO
Mailing Address - State:WV
Mailing Address - Zip Code:25917-0337
Mailing Address - Country:US
Mailing Address - Phone:304-469-2905
Mailing Address - Fax:304-465-5486
Practice Address - Street 1:221 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840
Practice Address - Country:US
Practice Address - Phone:304-574-3960
Practice Address - Fax:304-574-2179
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00741363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000503Medicaid
WV2030161Medicare PIN
WV2030162Medicare PIN