Provider Demographics
NPI:1053695957
Name:JOHNSON, JUDAH CHARLES (PA)
Entity type:Individual
Prefix:
First Name:JUDAH
Middle Name:CHARLES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:811 13TH ST
Mailing Address - Street 2:SUITE 20
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2700
Mailing Address - Country:US
Mailing Address - Phone:706-722-3401
Mailing Address - Fax:706-724-6540
Practice Address - Street 1:811 13TH ST
Practice Address - Street 2:SUITE 20
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2700
Practice Address - Country:US
Practice Address - Phone:706-722-3401
Practice Address - Fax:706-724-6540
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant