Provider Demographics
NPI:1669347951
Name:JOHNSON, TREVOR R
Entity type:Individual
Prefix:MR
First Name:TREVOR
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 WITHERDEN RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NY
Mailing Address - Zip Code:14505-9319
Mailing Address - Country:US
Mailing Address - Phone:585-278-8583
Mailing Address - Fax:
Practice Address - Street 1:367 E MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-1643
Practice Address - Country:US
Practice Address - Phone:315-787-4977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-07
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF357797-01363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care