Provider Demographics
NPI:1619971561
Name:JOHNSON, GLEN F (PA)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:F
Last Name:JOHNSON
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:PO BOX 1070
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28201-1070
Mailing Address - Country:US
Mailing Address - Phone:800-476-8646
Mailing Address - Fax:919-382-3210
Practice Address - Street 1:524 BEAUMONT RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4443
Practice Address - Country:US
Practice Address - Phone:800-476-8646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00010366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00390009OtherRAILROAD MEDICARE
NC2759010EMedicare PIN
NCP00390009OtherRAILROAD MEDICARE
NC2759010CMedicare PIN