Provider Demographics
NPI:1316051964
Name:JOHNSON, HENRY JR (PA-C)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:JOHNSON
Suffix:JR
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 1:1585 3RD ST
Mailing Address - Street 2:
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-5102
Mailing Address - Country:US
Mailing Address - Phone:337-531-3942
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant