Provider Demographics
NPI:1043278005
Name:JOHNSON, KYLE ERICK (PA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ERICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22063
Mailing Address - Street 2:DEPT 0289
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-2063
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:2929 S GARNETT RD
Practice Address - Street 2:C/O MEDCENTER
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5101
Practice Address - Country:US
Practice Address - Phone:918-665-1520
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1250363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP79497Medicare UPIN