Provider Demographics
NPI:1568567535
Name:JOHNSON, WILLIAM KENDALL (PAC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:KENDALL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SHERIDAN SQUARE
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660
Mailing Address - Country:US
Mailing Address - Phone:423-392-6840
Mailing Address - Fax:423-392-6845
Practice Address - Street 1:3 SHERIDAN SQUARE
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-392-6840
Practice Address - Fax:423-392-6845
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001104363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P99701Medicare UPIN
TN3662166Medicare PIN