Provider Demographics
NPI:1053550350
Name:JOHNSON, DAVID P (PA)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SOMERSET STREET
Mailing Address - Street 2:
Mailing Address - City:MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04462
Mailing Address - Country:US
Mailing Address - Phone:207-723-5161
Mailing Address - Fax:207-564-4370
Practice Address - Street 1:165 POPLAR STREET
Practice Address - Street 2:SUITE #1
Practice Address - City:MILLINOCKET
Practice Address - State:ME
Practice Address - Zip Code:04462
Practice Address - Country:US
Practice Address - Phone:207-723-2034
Practice Address - Fax:207-723-3006
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
MEPA1157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical