Provider Demographics
NPI:1326132408
Name:JOHNSON, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:2878 FIVE FORKS TRICKUM RD
Mailing Address - Street 2:STE 2A
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5896
Mailing Address - Country:US
Mailing Address - Phone:678-344-8700
Mailing Address - Fax:
Practice Address - Street 1:289 GRAYSON HWY STE 2A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5726
Practice Address - Country:US
Practice Address - Phone:770-771-5560
Practice Address - Fax:678-344-8600
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1032237363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical