Provider Demographics
NPI:1871668525
Name:JOHNSTON, BRIAN S (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:S
Last Name:JOHNSTON
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:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6961
Mailing Address - Country:US
Mailing Address - Phone:270-538-6200
Mailing Address - Fax:270-538-6220
Practice Address - Street 1:1532 LONE OAK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7913
Practice Address - Country:US
Practice Address - Phone:270-538-6200
Practice Address - Fax:270-538-6220
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA813208800000X, 363A00000X, 363AM0700X
IL085-001922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208800000XAllopathic & Osteopathic PhysiciansUrology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100200860Medicaid
112837OtherHEALTH ALLIANCE
Q46148Medicare UPIN
KY7100200860Medicaid