Provider Demographics
NPI:1831259084
Name:JOHNSON, JIMMY EDWARD (PA)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1270 CANSECO LANE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602
Mailing Address - Country:US
Mailing Address - Phone:828-294-1116
Mailing Address - Fax:828-294-0096
Practice Address - Street 1:MOUNTAIN VIEW FAMILY PRACTICE
Practice Address - Street 2:1940 BRIARWOOD DRIVE
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-5497
Practice Address - Country:US
Practice Address - Phone:828-294-1116
Practice Address - Fax:828-294-0096
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100174363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q27859Medicare UPIN