Provider Demographics
NPI:1730778978
Name:JOHNSON, ANDREW W (MMS, PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MMS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1460
Mailing Address - Country:US
Mailing Address - Phone:619-756-4112
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE STE G1
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4624
Practice Address - Country:US
Practice Address - Phone:714-545-5550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59223363A00000X
363AM0700X, 363AS0400X
CA59223363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical