Provider Demographics
NPI:1417024969
Name:JOHNSON, MICHAEL D (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 W HARRIE ST
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1209
Mailing Address - Country:US
Mailing Address - Phone:906-293-9233
Mailing Address - Fax:906-293-9285
Practice Address - Street 1:502 W HARRIE ST
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868-1209
Practice Address - Country:US
Practice Address - Phone:906-293-9233
Practice Address - Fax:906-293-9285
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002886363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5411366OtherBLUE CROSS BLUE SHIELD
MI5411366OtherBLUE CROSS BLUE SHIELD