Provider Demographics
NPI:1093054033
Name:JOHNSON, CASEY BENJAMIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CASEY
Middle Name:BENJAMIN
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:PO BOX 52948
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-2948
Mailing Address - Country:US
Mailing Address - Phone:865-306-5675
Mailing Address - Fax:865-584-7712
Practice Address - Street 1:9430 PARK WEST BLVD STE 310
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4203
Practice Address - Country:US
Practice Address - Phone:865-690-5263
Practice Address - Fax:865-588-3740
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2291363A00000X
TNPA2291363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ000510Medicaid
10397I2335Medicare PIN