Provider Demographics
NPI:1770554537
Name:JOHNSON, NORMAN EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:NORMAN
Middle Name:EDWARD
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 1:2102 N COUNTRY CLUB RD
Mailing Address - Street 2:BLDG B
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2831
Mailing Address - Country:US
Mailing Address - Phone:520-795-8371
Mailing Address - Fax:
Practice Address - Street 1:2650 N WYATT DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6106
Practice Address - Country:US
Practice Address - Phone:520-320-4402
Practice Address - Fax:520-320-4406
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP05034Medicare UPIN
AZZ70038Medicare ID - Type Unspecified