Provider Demographics
NPI:1821570987
Name:JOHNSON, WILLIAM ALEXANDER (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALEXANDER
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 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8905
Mailing Address - Fax:765-935-4200
Practice Address - Street 1:1400 HIGHLAND RD STE 1
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-8810
Practice Address - Country:US
Practice Address - Phone:765-935-8905
Practice Address - Fax:765-939-4200
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
KYTC813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100593300Medicaid