Provider Demographics
NPI:1356303358
Name:JOHNSON, GILBERT H (PA)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:H
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 1:1304 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-1849
Mailing Address - Country:US
Mailing Address - Phone:715-832-0992
Mailing Address - Fax:
Practice Address - Street 1:1304 LAKE RD
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-1849
Practice Address - Country:US
Practice Address - Phone:715-832-0992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI218-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42946000Medicaid
WI0276 20195Medicare ID - Type Unspecified
WI42946000Medicaid