Provider Demographics
NPI:1326074337
Name:JOHNSON, THOMAS E (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US RT 60 EAST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:304-733-3143
Practice Address - Street 1:1347 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1513
Practice Address - Country:US
Practice Address - Phone:304-743-1407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA875363A00000X
WV873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
001930720OtherBCBS
KY000000524203OtherBCBS
1069986OtherDWC
WVP00372239OtherRAILROAD MEDICARE
KY95006169Medicaid
OH0111530Medicaid
P00330689OtherRAILROAD
KY0931032Medicare PIN