Provider Demographics
NPI:1982681292
Name:JOHNSON, RICKIE E (PA)
Entity Type:Individual
Prefix:MR
First Name:RICKIE
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 BROADWAY APT C214
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-5657
Mailing Address - Country:US
Mailing Address - Phone:337-278-8826
Mailing Address - Fax:801-775-6884
Practice Address - Street 1:7238 6TH ST BLDG 249
Practice Address - Street 2:
Practice Address - City:HILL AIR FORCE BASE
Practice Address - State:UT
Practice Address - Zip Code:84056-5213
Practice Address - Country:US
Practice Address - Phone:801-777-1155
Practice Address - Fax:801-775-6884
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1627755Medicaid
LA51573P152Medicare ID - Type Unspecified
LAR94291Medicare UPIN