Provider Demographics
NPI:1073787677
Name:JOHNSON, RANDY M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2200 WHITNEY AVENUE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3694
Mailing Address - Country:US
Mailing Address - Phone:203-281-4463
Mailing Address - Fax:203-287-2930
Practice Address - Street 1:2200 WHITNEY AVENUE
Practice Address - Street 2:SUITE 360
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3694
Practice Address - Country:US
Practice Address - Phone:203-281-4463
Practice Address - Fax:203-287-2930
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT002078363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400077903Medicare PIN