Provider Demographics
NPI:1942698519
Name:JOHNSON, JASON WARREN
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:WARREN
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 1:5210 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4518
Mailing Address - Country:US
Mailing Address - Phone:813-882-9986
Mailing Address - Fax:813-884-5616
Practice Address - Street 1:5210 WEBB RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-4518
Practice Address - Country:US
Practice Address - Phone:813-882-9986
Practice Address - Fax:813-884-5616
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9108170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical