Provider Demographics
NPI:1851313340
Name:JOHNSON, HAYWARD SR (PAC)
Entity Type:Individual
Prefix:
First Name:HAYWARD
Middle Name:
Last Name:JOHNSON
Suffix:SR
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3029 TIMBER RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75181-4040
Mailing Address - Country:US
Mailing Address - Phone:214-213-3241
Mailing Address - Fax:
Practice Address - Street 1:1720 COMMERCE ST STE B
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-6710
Practice Address - Country:US
Practice Address - Phone:972-205-3727
Practice Address - Fax:972-205-3444
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01606363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S93453Medicare UPIN