Provider Demographics
NPI:1942623541
Name:JOHNSON, SADIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SADIE
Middle Name:
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 1:1004 WEST 45TH ST
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845
Mailing Address - Country:US
Mailing Address - Phone:308-991-8621
Mailing Address - Fax:
Practice Address - Street 1:816 22ND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845
Practice Address - Country:US
Practice Address - Phone:308-991-8621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant