Provider Demographics
NPI:1992203830
Name:JOHNSON, BRYAN R (PA)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
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 1:6716 NW 11TH PL STE 200
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6716 NW 11TH PL STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4201
Practice Address - Country:US
Practice Address - Phone:352-331-9729
Practice Address - Fax:352-331-0136
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110858363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFP1NCOtherBCBS
FL0237411-00Medicaid
JF178YOtherMEDICARE
JG187ZOtherMEDICARE