Provider Demographics
NPI:1457769978
Name:JOHNSON, JOSHUA BRENT
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:BRENT
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 ACORN OAKS CIR APT 341
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-2088
Mailing Address - Country:US
Mailing Address - Phone:812-480-1427
Mailing Address - Fax:
Practice Address - Street 1:2341 MCCALLIE AVE STE 402
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3231
Practice Address - Country:US
Practice Address - Phone:423-698-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN186662163W00000X
TNAPN19125T367500000X
IN28181730A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ008971Medicaid