Provider Demographics
NPI:1639736432
Name:HERRON, JOHNATHON R (CSFA, CST)
Entity Type:Individual
Prefix:
First Name:JOHNATHON
Middle Name:R
Last Name:HERRON
Suffix:
Gender:M
Credentials:CSFA, CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18339 TIFFANY RENEE DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-7550
Mailing Address - Country:US
Mailing Address - Phone:228-861-8891
Mailing Address - Fax:
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2515
Practice Address - Country:US
Practice Address - Phone:228-867-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant