Provider Demographics
NPI:1497712483
Name:JOHNSON, RUSSELL P (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:P
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 1:7021 SPRING MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3818
Mailing Address - Country:US
Mailing Address - Phone:702-803-2222
Mailing Address - Fax:702-829-7269
Practice Address - Street 1:7021 SPRING MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3818
Practice Address - Country:US
Practice Address - Phone:702-803-2222
Practice Address - Fax:702-829-7269
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003569L208VP0000X, 363AM0700X
NVPA1753363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1336749811OtherGROUP NPI
NV1497712483Medicaid