Provider Demographics
NPI:1174517627
Name:JOHNSON, MICHAEL ANDREW (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:INTERNAL MEDICINE DEPARTMENT
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6796
Mailing Address - Country:US
Mailing Address - Phone:850-863-8202
Mailing Address - Fax:850-862-6148
Practice Address - Street 1:1005 MAR WALT DR
Practice Address - Street 2:INTERNAL MEDICINE DEPARTMENT
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-863-8202
Practice Address - Fax:850-862-6148
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10004773363A00000X
FLPA9104179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant