Provider Demographics
NPI:1215975362
Name:JOHNSON, ROGER DALE (FNP)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 WORTHINGTON DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-3180
Mailing Address - Country:US
Mailing Address - Phone:423-925-2600
Mailing Address - Fax:423-925-2600
Practice Address - Street 1:207 E MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-4633
Practice Address - Country:US
Practice Address - Phone:423-925-2600
Practice Address - Fax:423-925-2600
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN11991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3643768Medicaid
Q71587Medicare UPIN
TN3643768Medicaid
TN3643768Medicare PIN