Provider Demographics
NPI:1750788360
Name:JOHNSON, DAVID A (NP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2086 OLD HIGHWAY 135 NW
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-4014
Mailing Address - Country:US
Mailing Address - Phone:812-734-0303
Mailing Address - Fax:812-225-5145
Practice Address - Street 1:2086 OLD HIGHWAY 135 NW
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-4014
Practice Address - Country:US
Practice Address - Phone:812-734-0303
Practice Address - Fax:812-225-5145
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005336A363LF0000X
KY3009066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM53407009Medicare PIN