Provider Demographics
NPI:1154354223
Name:JOHNSON, BROOK A (PA)
Entity type:Individual
Prefix:MRS
First Name:BROOK
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
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 634811
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-4811
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 BLACKFORD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-1405
Practice Address - Country:US
Practice Address - Phone:423-778-6011
Practice Address - Fax:865-539-8008
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001176363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4104205OtherBLUE CROSS
AL009938377Medicaid
GA593101463BMedicaid
AL009938377Medicaid
TN4104205OtherBLUE CROSS