Provider Demographics
NPI:1831798321
Name:JOHNSON, TRENTON RYAN
Entity type:Individual
Prefix:
First Name:TRENTON
Middle Name:RYAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 KOONTZ AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CLENDENIN
Mailing Address - State:WV
Mailing Address - Zip Code:25045-9581
Mailing Address - Country:US
Mailing Address - Phone:304-548-7272
Mailing Address - Fax:304-542-7149
Practice Address - Street 1:107 KOONTZ AVE STE 200
Practice Address - Street 2:
Practice Address - City:CLENDENIN
Practice Address - State:WV
Practice Address - Zip Code:25045-9581
Practice Address - Country:US
Practice Address - Phone:304-548-7272
Practice Address - Fax:304-542-7149
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WV2508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant