Provider Demographics
NPI:1235102500
Name:JOHNSON, DANNY (PAC)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-243-8500
Mailing Address - Fax:702-363-8753
Practice Address - Street 1:2704 N TENAYA WAY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-243-8500
Practice Address - Fax:702-363-8753
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV3102574OtherMEDICAID
NV3102514Medicaid
P23133Medicare UPIN
NVFO620ZMedicare PIN
NV3102514Medicaid
NVV34300Medicare PIN