Provider Demographics
NPI:1841432549
Name:JOHNS, PHIL JR (PA)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:JOHNS
Suffix:JR
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16930 W CATAWBA AVE STE 200
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5639
Practice Address - Country:US
Practice Address - Phone:704-322-4020
Practice Address - Fax:704-282-3018
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA110002941363A00000X
NC0010-03808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1841432549Medicaid
SC2710PAMedicaid
NCNCA923BMedicare PIN