Provider Demographics
NPI:1508069980
Name:JOHNSON, ANDREW ROBERT (MPAS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:ROBERT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD # L-605
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-2265
Mailing Address - Fax:503-494-7664
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD # L-605
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-2265
Practice Address - Fax:503-494-7664
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1508069980OtherNPI