Provider Demographics
NPI:1699787721
Name:JOHNSON, MICHAEL D (PA)
Entity type:Individual
Prefix:
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 1:410 N STATE OF FRANKLIN RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6971
Mailing Address - Country:US
Mailing Address - Phone:423-975-2350
Mailing Address - Fax:423-975-2372
Practice Address - Street 1:410 N STATE OF FRANKLIN RD
Practice Address - Street 2:SUITE 120
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6971
Practice Address - Country:US
Practice Address - Phone:423-975-2350
Practice Address - Fax:423-975-2372
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN940363A00000X, 363AS0400X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1699787721Medicaid
TNP01038739OtherRAILROAD MEDICARE
TN1519882Medicaid
TN1519882Medicaid
TN103I977953Medicare PIN