Provider Demographics
NPI:1659379428
Name:JOHNSON, DANA W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DANA
Middle Name:W
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 1:1309 BLOOMINGDALE DR
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-5934
Mailing Address - Country:US
Mailing Address - Phone:919-468-3729
Mailing Address - Fax:
Practice Address - Street 1:1540 SUNDAY DR STE 214
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6000
Practice Address - Country:US
Practice Address - Phone:919-235-0222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000101636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R40223Medicare UPIN