Provider Demographics
NPI:1932100039
Name:JOHNSON, KYLE HARRIS (PA)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:HARRIS
Last Name:JOHNSON
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 1:1910 BLANDING ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-3520
Mailing Address - Country:US
Mailing Address - Phone:803-256-4107
Mailing Address - Fax:803-253-6655
Practice Address - Street 1:1910 BLANDING ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3520
Practice Address - Country:US
Practice Address - Phone:803-256-4107
Practice Address - Fax:803-253-6655
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0317PAMedicaid
SCAA0831Medicare UPIN
SCP00217465Medicare ID - Type Unspecified