Provider Demographics
NPI:1962784785
Name:JOHNSON, KENNETH RAY (PA-C)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RAY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 63185
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3001
Mailing Address - Country:US
Mailing Address - Phone:706-650-7546
Mailing Address - Fax:706-922-9168
Practice Address - Street 1:1203 TOWN PARK LN
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809
Practice Address - Country:US
Practice Address - Phone:706-650-7546
Practice Address - Fax:706-922-9168
Is Sole Proprietor?:No
Enumeration Date:2011-09-19
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6259363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical