Provider Demographics
NPI:1457657348
Name:JOHNSON, ROBERT WILLIAM (PA- C)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WILLIAM
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 1:4843 PINEDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2101
Mailing Address - Country:US
Mailing Address - Phone:716-310-0973
Mailing Address - Fax:
Practice Address - Street 1:404 HATFIELD CT
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-1126
Practice Address - Country:US
Practice Address - Phone:910-738-3358
Practice Address - Fax:910-738-9174
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-10
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant