Provider Demographics
NPI:1609969674
Name:JOHNSON, ROBERT EDWARD (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
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 1:125 SW 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696-2403
Mailing Address - Country:US
Mailing Address - Phone:352-528-2801
Mailing Address - Fax:
Practice Address - Street 1:125 SW 7TH ST
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2403
Practice Address - Country:US
Practice Address - Phone:352-528-2801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9102838363A00000X
NC0010-02065363AM0700X
GA005331363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP1025Medicare PIN
S77124Medicare UPIN