Provider Demographics
NPI:1255368882
Name:JOHNSON, DARREL (PA-C)
Entity type:Individual
Prefix:
First Name:DARREL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
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:PO BOX 86430
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-6430
Mailing Address - Country:US
Mailing Address - Phone:605-322-4900
Mailing Address - Fax:605-322-4910
Practice Address - Street 1:1200 S 7TH AVE
Practice Address - Street 2:STE 2
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0998
Practice Address - Country:US
Practice Address - Phone:605-336-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0266363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6826102Medicaid
SD100793Medicare ID - Type Unspecified
SDP00341410Medicare PIN