Individual
PRISCILLA PHAN JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1100 W LAKE COMMONS DR, MARTINEZ, GA 30907-7932
(706) 250-6919
Mailing address
PO BOX 11037, PENSACOLA, FL 32524-1037
(850) 444-7000
(850) 444-7497
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
11803
GA
363A00000X
Physician Assistant
Primary
11803
GA
363A00000X
Physician Assistant
PA9110351
FL
363AM0700X
Medical Physician Assistant
PA9110351
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
020947500
—
FL
01
—
PA9110351
FLORIDA STATE DOH MEDICAL LICENSURE
FL
Enumeration date
04/26/2017
Last updated
12/01/2023
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