Provider Demographics
NPI:1689862450
Name:JOHNSON, AUTUMN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-7439
Mailing Address - Fax:
Practice Address - Street 1:7910 FROST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-2771
Practice Address - Country:US
Practice Address - Phone:858-634-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA51290363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant