Provider Demographics
NPI:1407105547
Name:JOHNSON, ANTHONY WILLIAM (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:ANTHONY
Other - Middle Name:WILLIAM
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C, MS, MS
Mailing Address - Street 1:1094 S BLAIR ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4703
Mailing Address - Country:US
Mailing Address - Phone:702-885-6791
Mailing Address - Fax:
Practice Address - Street 1:1094 S BLAIR ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4703
Practice Address - Country:US
Practice Address - Phone:702-885-6791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA158656363A00000X
UT366543-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant