Provider Demographics
NPI:1336116003
Name:JOHNSON, GARY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LYNN
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 1:107 ROCKY STEP RD
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-9631
Mailing Address - Country:US
Mailing Address - Phone:304-412-4243
Mailing Address - Fax:
Practice Address - Street 1:610 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1251
Practice Address - Country:US
Practice Address - Phone:304-766-7515
Practice Address - Fax:304-766-7566
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1071247OtherWV DWC
WV01092OtherLICENSE
WV01092OtherLICENSE
WV1071247OtherWV DWC
WVJOPA23452Medicare PIN