Provider Demographics
NPI:1114162419
Name:JOHNSON, JAIRUS L (PA)
Entity Type:Individual
Prefix:
First Name:JAIRUS
Middle Name:L
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 1:2001 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3280
Mailing Address - Country:US
Mailing Address - Phone:410-481-1000
Mailing Address - Fax:
Practice Address - Street 1:2001 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3280
Practice Address - Country:US
Practice Address - Phone:410-481-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant