Provider Demographics
NPI:1497151922
Name:JOHNSON, BLAKE WESLEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:WESLEY
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 1:2000 S WHEELING AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5647
Mailing Address - Country:US
Mailing Address - Phone:918-403-6284
Mailing Address - Fax:918-403-6323
Practice Address - Street 1:2000 S WHEELING AVE STE 900
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5647
Practice Address - Country:US
Practice Address - Phone:918-403-6284
Practice Address - Fax:918-403-6323
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-11
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant