Provider Demographics
NPI:1871963728
Name:JOHNSON, CORINE N (NP-C)
Entity type:Individual
Prefix:
First Name:CORINE
Middle Name:N
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3338 OAKWELL CT STE 114
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-3087
Mailing Address - Country:US
Mailing Address - Phone:210-268-0120
Mailing Address - Fax:
Practice Address - Street 1:855 PROTON RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4203
Practice Address - Country:US
Practice Address - Phone:210-614-1234
Practice Address - Fax:210-614-0952
Is Sole Proprietor?:No
Enumeration Date:2015-10-05
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129216363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354403302Medicaid
TX462011YQE5OtherMEDICARE
TX462011YX7WOtherMEDICARE
TX354403301Medicaid