Provider Demographics
NPI:1518933134
Name:JOHNSON, GREGORY ALAN (P A - C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:P A - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5191 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-4249
Mailing Address - Country:US
Mailing Address - Phone:770-498-9717
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2613
Practice Address - Country:US
Practice Address - Phone:404-616-2949
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant