Provider Demographics
NPI:1982631156
Name:JOHNSON, LAYNE BROUSSARD (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:LAYNE
Middle Name:BROUSSARD
Last Name:JOHNSON
Suffix:
Gender:F
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 1:10374 HIGHWAY 165 N STE B
Mailing Address - Street 2:
Mailing Address - City:STERLINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:71280-3320
Mailing Address - Country:US
Mailing Address - Phone:318-665-4543
Mailing Address - Fax:
Practice Address - Street 1:10374 HIGHWAY 165 N STE B
Practice Address - Street 2:
Practice Address - City:STERLINGTON
Practice Address - State:LA
Practice Address - Zip Code:71280-3320
Practice Address - Country:US
Practice Address - Phone:318-665-4543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10595RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1627747Medicaid
LA278869YQZTMedicare PIN