Provider Demographics
NPI:1376027870
Name:JOHNSON, ANDREW DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:DAVID
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 1:823 FLOWERING PLUM DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-7098
Mailing Address - Country:US
Mailing Address - Phone:810-360-8163
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1896
Practice Address - Country:US
Practice Address - Phone:517-364-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant