Provider Demographics
NPI:1104275791
Name:JOHNSON, ERIC MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:MICHAEL
Last Name:JOHNSON
Suffix:
Gender:M
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 1446
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-1446
Mailing Address - Country:US
Mailing Address - Phone:910-620-3189
Mailing Address - Fax:
Practice Address - Street 1:120 S SPALDING DR
Practice Address - Street 2:SUITE 401
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1800
Practice Address - Country:US
Practice Address - Phone:310-860-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant