Provider Demographics
NPI:1194745877
Name:JOHNSON, KEVIN RUSSELL (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:RUSSELL
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 1:5541 GOODWIN AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-6212
Mailing Address - Country:US
Mailing Address - Phone:817-343-0431
Mailing Address - Fax:
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:817-343-0431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04026OtherSTATE LICENSE #
TXY0133663OtherTX DPS #
TXMJ1109140OtherDEA #