Provider Demographics
NPI:1316594997
Name:MYERS, JOHNNY W
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:W
Last Name:MYERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8493
Practice Address - Street 1:550 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45345-9172
Practice Address - Country:US
Practice Address - Phone:937-687-1911
Practice Address - Fax:937-687-1888
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.426759163W00000X
OHLE-00029703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0372742Medicaid