Provider Demographics
NPI:1841373958
Name:JOHNSON, KEVRIN J (PA-C)
Entity type:Individual
Prefix:
First Name:KEVRIN
Middle Name:J
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 1:120 WILLIAM PENN PLZ
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2150
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:919-313-1276
Practice Address - Street 1:107 E MCCLANAHAN ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NC
Practice Address - Zip Code:27565-2919
Practice Address - Country:US
Practice Address - Phone:919-690-8588
Practice Address - Fax:919-313-1276
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5931994-3902106H00000X
NC0010-03936363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist