Provider Demographics
NPI:1851705347
Name:JOHNSON, DREW AUGUST (PA-C)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:AUGUST
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8836 N HESS ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8718
Mailing Address - Country:US
Mailing Address - Phone:208-762-7760
Mailing Address - Fax:208-762-7740
Practice Address - Street 1:8836 N HESS ST
Practice Address - Street 2:SUITE C
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8718
Practice Address - Country:US
Practice Address - Phone:208-762-7760
Practice Address - Fax:208-762-7740
Is Sole Proprietor?:No
Enumeration Date:2014-06-12
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1167363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant