Provider Demographics
NPI:1306021753
Name:JOHNSON, CRAIG (PA-C)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
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 1:10026 OLD OCEAN CITY BLVD
Mailing Address - Street 2:BUILDING ONE
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811
Mailing Address - Country:US
Mailing Address - Phone:410-641-0430
Mailing Address - Fax:410-641-3871
Practice Address - Street 1:10344 OLD OCEAN CITY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-641-0430
Practice Address - Fax:410-641-3871
Is Sole Proprietor?:No
Enumeration Date:2008-01-04
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001907363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP34877Medicare UPIN
MDKP955917Medicare PIN