Provider Demographics
NPI:1225380629
Name:JOHNSON, PATRICK ALAN (RD, PA-C)
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 N CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1592
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:825 N CENTER AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1592
Practice Address - Country:US
Practice Address - Phone:989-731-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012837363A00000X
WADI60312524133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
DI60312524OtherWASHINGTON DIETITIAN LICENSURE