Provider Demographics
NPI:1275719650
Name:JOHNSON, SCOTT ROGER (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ROGER
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:PO BOX 3300
Mailing Address - Street 2:
Mailing Address - City:LA PINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-3300
Mailing Address - Country:US
Mailing Address - Phone:541-536-3435
Mailing Address - Fax:541-536-8047
Practice Address - Street 1:51600 HUNTINGTON RD
Practice Address - Street 2:
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-8887
Practice Address - Country:US
Practice Address - Phone:541-536-3435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR00826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant