Provider Demographics
NPI:1538319587
Name:JOHNSON, BRENDA L (PA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W INTERSTATE 20 STE 132
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5851
Mailing Address - Country:US
Mailing Address - Phone:682-274-8181
Mailing Address - Fax:817-764-0175
Practice Address - Street 1:801 W INTERSTATE 20 STE 132
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5851
Practice Address - Country:US
Practice Address - Phone:682-274-8181
Practice Address - Fax:817-764-0175
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05858363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8100NROtherBCBS
TX297908003Medicaid
TX297908005Medicaid
TX532836YKYCMedicare PIN
TX412849YSY7Medicare PIN