1972667749 NPI number — MRS. SUSAN MCCAMBLY JOHNSON PHYSICIAN ASSISTANT

Table of content: MRS. SUSAN MCCAMBLY JOHNSON PHYSICIAN ASSISTANT (NPI 1972667749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972667749 NPI number — MRS. SUSAN MCCAMBLY JOHNSON PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
SUSAN
Provider Middle Name:
MCCAMBLY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLY
Provider Other First Name:
SUSAN
Provider Other Middle Name:
MCCAMBLY
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN FORMERLY
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972667749
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2750 GREENSCREEK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-522-0167
Provider Business Mailing Address Fax Number:
907-646-2573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 LAKE OTIS PKWY
Provider Second Line Business Practice Location Address:
STE. 322
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508-5222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-562-1234
Provider Business Practice Location Address Fax Number:
907-561-8550
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  531 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 531 . This is a "STATELIC" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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