Provider Demographics
NPI:1770529919
Name:JOHNSON, C BEN (PA-C)
Entity type:Individual
Prefix:MR
First Name:C
Middle Name:BEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:CLAUDE
Other - Middle Name:BENJAMIN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:325 PARK ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-4229
Mailing Address - Country:US
Mailing Address - Phone:541-451-7200
Mailing Address - Fax:541-451-7229
Practice Address - Street 1:325 PARK ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-4229
Practice Address - Country:US
Practice Address - Phone:541-451-7200
Practice Address - Fax:541-451-7229
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS40032Medicare UPIN