Provider Demographics
NPI:1336301480
Name:JOHNSON, BENJAMIN L (PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5733 107TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-8247
Mailing Address - Country:US
Mailing Address - Phone:806-792-4329
Mailing Address - Fax:806-795-0986
Practice Address - Street 1:2703 82ND ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1429
Practice Address - Country:US
Practice Address - Phone:806-761-0333
Practice Address - Fax:806-782-0097
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0508023602255A2300X
TXPA09255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer