Provider Demographics
NPI:1518558691
Name:JOHNSON, KALEB (PA-C)
Entity Type:Individual
Prefix:
First Name:KALEB
Middle Name:
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 1:8051 S EMERSON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8632
Mailing Address - Country:US
Mailing Address - Phone:317-865-2955
Mailing Address - Fax:317-865-2944
Practice Address - Street 1:8051 S EMERSON AVE STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8632
Practice Address - Country:US
Practice Address - Phone:317-865-2955
Practice Address - Fax:317-865-2944
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003658A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant