Provider Demographics
NPI:1821010109
Name:JOHNSON, CHADWICK T (ACNP)
Entity Type:Individual
Prefix:
First Name:CHADWICK
Middle Name:T
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:ACNP
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 SCOTT AND WHITE DR
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6441
Practice Address - Country:US
Practice Address - Phone:979-207-0100
Practice Address - Fax:979-207-2161
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX604645207P00000X, 363LF0000X
TXAP111203363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP43247Medicare UPIN