Provider Demographics
NPI:1780652974
Name:JOHNSON, THOMAS W (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
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 1:600 NOKOMIS AVE S
Mailing Address - Street 2:SUITE 102 & 203
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-3209
Mailing Address - Country:US
Mailing Address - Phone:941-486-6979
Mailing Address - Fax:
Practice Address - Street 1:600 NOKOMIS AVE S
Practice Address - Street 2:SUITE 102 & 203
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3209
Practice Address - Country:US
Practice Address - Phone:941-486-6979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK544363A00000X
FLPA9107926363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
24R602764Medicare PIN