Provider Demographics
NPI:1104101716
Name:JOHNSON, STEVEN BOYD (PA-C)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:BOYD
Last Name:JOHNSON
Suffix:
Gender:
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:PO BOX 775641
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:479-250-1053
Mailing Address - Fax:479-250-0923
Practice Address - Street 1:3101 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4900
Practice Address - Country:US
Practice Address - Phone:479-250-1053
Practice Address - Fax:479-250-0923
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-457363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR267015YJLKOtherMEDICARE PTAN