Provider Demographics
NPI:1215128970
Name:JOHNSON, MICHAEL DAVID (PAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HOSPITAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-6200
Mailing Address - Country:US
Mailing Address - Phone:703-547-7617
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-6200
Practice Address - Country:US
Practice Address - Phone:703-547-7617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant