Provider Demographics
NPI:1962619932
Name:JOHNSON, DAVID SHANE (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:SHANE
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 769
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-0769
Mailing Address - Country:US
Mailing Address - Phone:601-849-1475
Mailing Address - Fax:601-849-1549
Practice Address - Street 1:376A SIMPSON HIGHWAY 149
Practice Address - Street 2:
Practice Address - City:MAGEE
Practice Address - State:MS
Practice Address - Zip Code:39111-3409
Practice Address - Country:US
Practice Address - Phone:601-849-1475
Practice Address - Fax:601-849-1549
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125918Medicaid
MS00125918Medicaid