Provider Demographics
NPI:1003313727
Name:JOHNSON, MICHAEL OLTON (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:OLTON
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 1:377 W PIKE ST # A3-2
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4881
Mailing Address - Country:US
Mailing Address - Phone:470-461-7031
Mailing Address - Fax:770-502-6820
Practice Address - Street 1:377 W PIKE ST # A3-2
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4881
Practice Address - Country:US
Practice Address - Phone:470-461-7031
Practice Address - Fax:770-502-6820
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11074363A00000X
NY021943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant