Provider Demographics
NPI:1184790768
Name:JOHNSON, TIMOTHY W (MS PA C)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MS 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:PO BOX 3633
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:AK
Mailing Address - Zip Code:99664-3633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33280 STONEY CREEK AVE
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664-3633
Practice Address - Country:US
Practice Address - Phone:907-224-7094
Practice Address - Fax:907-224-7094
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCL3490Medicaid
S85915Medicare UPIN
AKCL3490Medicaid