Provider Demographics
NPI:1962746172
Name:JOHNSON, DEREK A (PA-C)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:A
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 1:701 NW 13TH ST FL 3
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2305
Mailing Address - Country:US
Mailing Address - Phone:561-955-5790
Mailing Address - Fax:561-955-5791
Practice Address - Street 1:701 NW 13TH ST FL 3
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2305
Practice Address - Country:US
Practice Address - Phone:561-955-5790
Practice Address - Fax:561-955-5791
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3011968OtherCIGNA
FL398531OtherAVMED
FLP01707166OtherRR MEDICARE
FL1039541OtherFREEDOM
FL4179920OtherAETNA
FL974430OtherOPTIMUM
FLIFS7ZOtherBCBS
FL974430OtherOPTIMUM