Provider Demographics
NPI:1598305252
Name:JOHNSON, WESLEY RAY JOSEPH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:RAY JOSEPH
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 1:1901 TATE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1109
Mailing Address - Country:US
Mailing Address - Phone:434-200-3000
Mailing Address - Fax:
Practice Address - Street 1:720 WYNDHURST DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24502-2698
Practice Address - Country:US
Practice Address - Phone:910-616-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant