Provider Demographics
NPI:1053568170
Name:JOHNSON, ROGER ALAN (PA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:ALAN
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 1:1949 GUNBARREL RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3188
Mailing Address - Country:US
Mailing Address - Phone:423-664-4635
Mailing Address - Fax:423-664-4640
Practice Address - Street 1:1949 GUNBARREL RD
Practice Address - Street 2:SUITE 125
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3188
Practice Address - Country:US
Practice Address - Phone:423-664-4635
Practice Address - Fax:423-664-4640
Is Sole Proprietor?:No
Enumeration Date:2008-08-20
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNR89868Medicare UPIN