Provider Demographics
NPI:1700971116
Name:JOHNSON, GARY M (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
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 1:680 S ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-4113
Mailing Address - Country:US
Mailing Address - Phone:775-329-6300
Mailing Address - Fax:775-323-3136
Practice Address - Street 1:1055 S WELLS AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-2586
Practice Address - Country:US
Practice Address - Phone:775-329-6300
Practice Address - Fax:775-323-3136
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003116008Medicaid
NV001516008Medicaid
NV003116008Medicaid