Provider Demographics
NPI:1841301843
Name:JOHNSTON, PAUL EDGAR (CP, C-PED)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:EDGAR
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:CP, C-PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3317
Mailing Address - Country:US
Mailing Address - Phone:507-860-6910
Mailing Address - Fax:501-860-7587
Practice Address - Street 1:119 W CARPENTER ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3317
Practice Address - Country:US
Practice Address - Phone:507-860-6910
Practice Address - Fax:501-860-7587
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49920OtherAR BLUECROSS BLUESHIELD
AR49920OtherAR BLUECROSS BLUESHIELD