Provider Demographics
NPI:1437538410
Name:JOHNSON, CHARLES DAVID (AGACNP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DAVID
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PROFESSIONAL PKWY STE 126
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2647
Mailing Address - Country:US
Mailing Address - Phone:601-450-0521
Mailing Address - Fax:601-450-0518
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-7000
Practice Address - Fax:601-450-0518
Is Sole Proprietor?:No
Enumeration Date:2015-05-24
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR875364363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03600303Medicaid