Provider Demographics
NPI:1316490337
Name:JOHNSON, DAVID MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
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:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-0683
Mailing Address - Country:US
Mailing Address - Phone:360-466-3167
Mailing Address - Fax:
Practice Address - Street 1:17400 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8801
Practice Address - Country:US
Practice Address - Phone:360-466-3167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60792211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant