Provider Demographics
NPI:1922042522
Name:JOHNSON, PETER (AA-C, PA-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:AA-C, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 WOODSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:STREET
Mailing Address - State:MD
Mailing Address - Zip Code:21154-1115
Mailing Address - Country:US
Mailing Address - Phone:410-452-5599
Mailing Address - Fax:
Practice Address - Street 1:1009 WOODSHIRE LN
Practice Address - Street 2:
Practice Address - City:STREET
Practice Address - State:MD
Practice Address - Zip Code:21154-1115
Practice Address - Country:US
Practice Address - Phone:410-452-5599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0000466363A00000X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP07480Medicare UPIN