Provider Demographics
NPI:1073273660
Name:JOHNSON, LAVAROUS ANTWON (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:LAVAROUS
Middle Name:ANTWON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W FLETCHER AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-3415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 W KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-1450
Practice Address - Country:US
Practice Address - Phone:757-528-7563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical