Provider Demographics
NPI:1598732737
Name:JOHNSON, BRYAN S (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:S
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 1:2000 S MAYS ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7580
Mailing Address - Country:US
Mailing Address - Phone:512-244-4272
Mailing Address - Fax:512-244-2895
Practice Address - Street 1:2000 S MAYS ST STE 201
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7580
Practice Address - Country:US
Practice Address - Phone:512-244-4272
Practice Address - Fax:512-244-2895
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04205363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200086106Medicaid
TXQ28306Medicare UPIN