Provider Demographics
NPI:1588627376
Name:JOHANSON, PAXTON MCKEOWN (PA)
Entity Type:Individual
Prefix:MR
First Name:PAXTON
Middle Name:MCKEOWN
Last Name:JOHANSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 PRINCETON AVE SW
Mailing Address - Street 2:200A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35211
Mailing Address - Country:US
Mailing Address - Phone:205-786-2776
Mailing Address - Fax:205-786-6227
Practice Address - Street 1:833 PRINCETON AVE SW
Practice Address - Street 2:200A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211
Practice Address - Country:US
Practice Address - Phone:205-786-2776
Practice Address - Fax:205-786-6227
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102616363AS0400X
ALPA-469363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291696700Medicaid
AL051558292JOHMedicare PIN
Q05059Medicare UPIN