Provider Demographics
NPI:1578658746
Name:JOHNSON, MARK (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
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 1:10755 SCRIPPS POWAY PKWY
Mailing Address - Street 2:STE 383
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3924
Mailing Address - Country:US
Mailing Address - Phone:203-257-9951
Mailing Address - Fax:
Practice Address - Street 1:1725 GENTLE BREEZE LN
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1968
Practice Address - Country:US
Practice Address - Phone:203-257-9951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000901146D00000X
CAPA21728363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970001465Medicare ID - Type Unspecified