Provider Demographics
NPI:1063489623
Name:JOHNSON, THOMAS M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:M
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 1:204 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-1806
Mailing Address - Country:US
Mailing Address - Phone:814-864-4755
Mailing Address - Fax:814-864-5430
Practice Address - Street 1:204 W 26TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16508-1806
Practice Address - Country:US
Practice Address - Phone:814-864-4755
Practice Address - Fax:814-864-5430
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ24975Medicare UPIN
PA083890FR6Medicare PIN
PA083891HXKMedicare PIN