Provider Demographics
NPI:1891404539
Name:JOHNSON, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 BORING CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-2943
Mailing Address - Country:US
Mailing Address - Phone:423-833-5549
Mailing Address - Fax:
Practice Address - Street 1:436 BORING CHAPEL RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:TN
Practice Address - Zip Code:37615-2943
Practice Address - Country:US
Practice Address - Phone:423-833-5549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33066363L00000X
TN164131163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse