Provider Demographics
NPI:1073533725
Name:JOHNSON, MICHAEL HOWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:HOWARD
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 1:9157 STEINER ST
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-6197
Mailing Address - Country:US
Mailing Address - Phone:210-392-6186
Mailing Address - Fax:
Practice Address - Street 1:4504 BOAT CLUB RD STE 800
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-7002
Practice Address - Country:US
Practice Address - Phone:817-237-0515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01163363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical