Provider Demographics
NPI:1275054850
Name:JOHNSON, TRAVIS DAVID (AA)
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7950 COLQUITT RD APT B2
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4019
Mailing Address - Country:US
Mailing Address - Phone:229-520-1419
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-04
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA8526367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program