Provider Demographics
NPI:1285824623
Name:JOHNSON, NATHAN ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:ALLEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3572 BRODHEAD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-3101
Mailing Address - Country:US
Mailing Address - Phone:724-728-6539
Mailing Address - Fax:724-728-7416
Practice Address - Street 1:3572 BRODHEAD RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MONACA
Practice Address - State:PA
Practice Address - Zip Code:15061-3101
Practice Address - Country:US
Practice Address - Phone:724-728-6539
Practice Address - Fax:724-728-7416
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT1835092085R0202X
PAMD4338692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2045019OtherBLUE CROSS BLUE SHIELD
WV3810013349Medicaid
PA1021877070001Medicaid
PA125482Medicare PIN