Provider Demographics
NPI:1508855677
Name:JOHNSON, MARK DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DANIEL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 W TECUMSEH RD
Mailing Address - Street 2:STE 101
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-1810
Mailing Address - Country:US
Mailing Address - Phone:405-360-6764
Mailing Address - Fax:405-360-6769
Practice Address - Street 1:13401 N WESTERN AVE STE 301
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-1411
Practice Address - Country:US
Practice Address - Phone:405-360-6764
Practice Address - Fax:405-360-6769
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK485363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
248429007Medicare ID - Type Unspecified
R19195Medicare UPIN