Provider Demographics
NPI:1093715013
Name:JOHNSON, BRENT M (PA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:M
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 1:5656 W US HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2454
Mailing Address - Country:US
Mailing Address - Phone:231-843-2543
Mailing Address - Fax:231-843-2547
Practice Address - Street 1:5656 W US HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2454
Practice Address - Country:US
Practice Address - Phone:231-843-2543
Practice Address - Fax:231-843-2547
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICJ0662OtherMEDICARE RAILROAD
MI5601003020OtherMEDICAL LICENSE
MI5601003020OtherMEDICAL LICENSE