Provider Demographics
NPI:1053981365
Name:JOHNSON, MARIANNE ROXIE
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:ROXIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10597
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78766-1597
Mailing Address - Country:US
Mailing Address - Phone:512-448-4588
Mailing Address - Fax:512-445-4511
Practice Address - Street 1:4310 JAMES CASEY ST STE 4A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1120
Practice Address - Country:US
Practice Address - Phone:512-448-4588
Practice Address - Fax:512-445-4511
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-29
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant