Provider Demographics
NPI:1902829583
Name:JOHNSON, KEITH ALLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9350
Mailing Address - Country:US
Mailing Address - Phone:570-522-4110
Mailing Address - Fax:570-768-3911
Practice Address - Street 1:7055 WESTBRANCH HWY
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-6808
Practice Address - Country:US
Practice Address - Phone:570-524-4141
Practice Address - Fax:570-524-5218
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003170L363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50012614OtherCAPITAL BLUE CROSS
PAP00214218OtherRAILROAD MEDICARE
PA50012614OtherCAPITAL BLUE CROSS
PA50012614OtherCAPITAL BLUE CROSS