Provider Demographics
NPI:1376840421
Name:JOHNSON, JOSHUA R (PA)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:R
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 1:400 S KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2682
Mailing Address - Country:US
Mailing Address - Phone:815-928-8050
Mailing Address - Fax:800-505-2218
Practice Address - Street 1:400 S. KENNEDY
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915
Practice Address - Country:US
Practice Address - Phone:815-928-8050
Practice Address - Fax:800-505-2218
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003901363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical