Provider Demographics
NPI:1568453132
Name:JOHNSON, MARK SAMUEL (PA-C MT ASCP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:SAMUEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C MT ASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:300 1ST CAPITOL DR
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2844
Practice Address - Country:US
Practice Address - Phone:636-947-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010013488363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant