Provider Demographics
NPI:1043385008
Name:JOHNSON, SUSAN RUTH (PA-C)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RUTH
Last Name: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 1883
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-1883
Mailing Address - Country:US
Mailing Address - Phone:360-894-0256
Mailing Address - Fax:
Practice Address - Street 1:91 SW CHEHALIS AVE STE 101
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-1934
Practice Address - Country:US
Practice Address - Phone:360-740-5181
Practice Address - Fax:360-740-6007
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0215145OtherL AND I