Provider Demographics
NPI:1225087687
Name:JOHNSON, JEFFREY NORMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:NORMAN
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 1:2845 PGA BLVD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2910
Mailing Address - Country:US
Mailing Address - Phone:561-693-0540
Mailing Address - Fax:561-296-6174
Practice Address - Street 1:264 NW PEACOCK BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2272
Practice Address - Country:US
Practice Address - Phone:772-323-2523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101353363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP12412Medicare UPIN
FLE4452XMedicare ID - Type Unspecified
FLE4452YMedicare ID - Type Unspecified
FLE4452ZMedicare ID - Type Unspecified
FLE4452WMedicare ID - Type Unspecified