Provider Demographics
NPI:1114940087
Name:JOHNSON, CHARLES M JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:M
Last Name:JOHNSON
Suffix:JR
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 1:3444 MASONIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-441-8310
Practice Address - Street 1:3444 MASONIC DRIVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-473-9556
Practice Address - Fax:318-441-8310
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA30094363A00000X
LAPA.A10372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP10098Medicare UPIN
5W948P227Medicare ID - Type Unspecified