Provider Demographics
NPI:1922607399
Name:JOHNSON, TAQUAN
Entity Type:Individual
Prefix:
First Name:TAQUAN
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 1:2727 WOODSDALE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-6891
Mailing Address - Country:US
Mailing Address - Phone:904-910-8426
Mailing Address - Fax:
Practice Address - Street 1:2727 WOODSDALE DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-6891
Practice Address - Country:US
Practice Address - Phone:904-910-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-18
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty