Provider Demographics
NPI:1982147930
Name:JOHANSEN, JOSHUA ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ALLEN
Last Name:JOHANSEN
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 1:2015 GUM BRANCH RD APT 817
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-5074
Mailing Address - Country:US
Mailing Address - Phone:503-560-1677
Mailing Address - Fax:
Practice Address - Street 1:1250 BIRCH ST
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2529
Practice Address - Country:US
Practice Address - Phone:950-451-1095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant