Provider Demographics
NPI:1801082821
Name:JOHNSON, LAVON M (PA)
Entity type:Individual
Prefix:MS
First Name:LAVON
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:LAVON
Other - Middle Name:M
Other - Last Name:ORRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 E HWY 60
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-8258
Practice Address - Country:US
Practice Address - Phone:417-354-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007004098363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO# PENDINGMedicare PIN