Provider Demographics
NPI:1669607800
Name:JOHNSON, MATTHEW J (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 COLE AVE
Mailing Address - Street 2:
Mailing Address - City:BISBEE
Mailing Address - State:AZ
Mailing Address - Zip Code:85603-1327
Mailing Address - Country:US
Mailing Address - Phone:520-432-6481
Mailing Address - Fax:520-432-5082
Practice Address - Street 1:101 COLE AVE
Practice Address - Street 2:
Practice Address - City:BISBEE
Practice Address - State:AZ
Practice Address - Zip Code:85603-1327
Practice Address - Country:US
Practice Address - Phone:520-432-6481
Practice Address - Fax:520-432-5082
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0007363AM0700X, 363AM0700X
AZ8117363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical