Provider Demographics
NPI:1649212440
Name:GASTON, JOHNNY EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:EUGENE
Last Name:GASTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:E
Other - Last Name:GASTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD DBA
Mailing Address - Street 1:2312B MURCHISON RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-3518
Mailing Address - Country:US
Mailing Address - Phone:910-488-6331
Mailing Address - Fax:910-488-5351
Practice Address - Street 1:2312B MURCHISON RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3518
Practice Address - Country:US
Practice Address - Phone:910-488-6331
Practice Address - Fax:910-488-5351
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22112363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901585Medicaid
NC8934945Medicaid
NCF47959Medicare UPIN