Provider Demographics
NPI:1720546112
Name:JOHNSON, NOAH DEWAYNE JR (PHD)
Entity Type:Individual
Prefix:
First Name:NOAH
Middle Name:DEWAYNE
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11707 KINGSTON DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70807-2066
Mailing Address - Country:US
Mailing Address - Phone:225-302-3049
Mailing Address - Fax:
Practice Address - Street 1:11707 KINGSTON DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-2066
Practice Address - Country:US
Practice Address - Phone:225-302-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-05
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA005862169172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver