Provider Demographics
NPI:1093727653
Name:JOHNSON, BRIAN CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHRISTOPHER
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 1:109 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-3333
Mailing Address - Country:US
Mailing Address - Phone:864-224-5700
Mailing Address - Fax:864-226-0680
Practice Address - Street 1:109 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-3333
Practice Address - Country:US
Practice Address - Phone:864-224-5700
Practice Address - Fax:864-226-0680
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC961363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC961OtherSTATE LICENSE NUMBER
SC2251PAMedicaid
SCP0161435OtherRR MEDICARE
SCQ25893Medicare UPIN
SCAA06504306Medicare ID - Type UnspecifiedMEDICARE NUMBER