Provider Demographics
NPI:1003684317
Name:JOHNSON, JOSEPH A
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2791 W MINERAL BUTTE DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85144-4734
Mailing Address - Country:US
Mailing Address - Phone:623-703-5765
Mailing Address - Fax:
Practice Address - Street 1:2791 W MINERAL BUTTE DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85144-4734
Practice Address - Country:US
Practice Address - Phone:623-703-5765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ000000405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Single Specialty