Provider Demographics
NPI:1063689172
Name:JOHNSON, RYAN (PA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:
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 1:77 W UNDERWOOD ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1122
Mailing Address - Country:US
Mailing Address - Phone:407-649-6884
Mailing Address - Fax:407-245-7059
Practice Address - Street 1:77 W UNDERWOOD ST
Practice Address - Street 2:STE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1122
Practice Address - Country:US
Practice Address - Phone:407-649-6884
Practice Address - Fax:407-245-7059
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1078006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL293067600Medicaid
FLCC400ZMedicare PIN