Provider Demographics
NPI:1700287323
Name:JOHNSON, SHAMAR JERRELL
Entity Type:Individual
Prefix:MR
First Name:SHAMAR
Middle Name:JERRELL
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 1:7230 WURZBACH RD APT 306
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-3861
Mailing Address - Country:US
Mailing Address - Phone:210-326-5636
Mailing Address - Fax:
Practice Address - Street 1:7230 WURZBACH RD APT 306
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3861
Practice Address - Country:US
Practice Address - Phone:210-326-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility