Provider Demographics
NPI:1225336993
Name:JOHNSON, KEVIN SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:SCOTT
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 1:1850 W ARLINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5704
Mailing Address - Country:US
Mailing Address - Phone:252-413-6740
Mailing Address - Fax:252-752-6600
Practice Address - Street 1:1711 E ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5872
Practice Address - Country:US
Practice Address - Phone:252-355-4357
Practice Address - Fax:252-355-4187
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02180363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant