Provider Demographics
NPI:1790733368
Name:JOHN, JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:JOHN
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-5955
Mailing Address - Fax:757-446-5196
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-5955
Practice Address - Fax:757-446-5196
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023550363A00000X
VA0110001755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ29831Medicare UPIN
VA-029OtherTRICARE/CHAMPUS
VAPAROtherUSA MANAGED CARE
VA10060825POtherOPTIMA HEALTH
VAPAROtherCORVEL/CORCARE (EVMS HEALTH SERVICES)
VA1790733368Medicaid
VAVAA100937Medicare PIN
VAP00846021Medicare PIN
NC8101036Medicaid
TNQ29831Medicare UPIN
VAPAROtherCOVENTRY HEALTH CARE