Provider Demographics
NPI:1053870717
Name:JOHNSON, MATTHEW (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:900 OCEAN BEACH HWY STE 110
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4171
Mailing Address - Country:US
Mailing Address - Phone:360-648-8860
Mailing Address - Fax:360-648-8865
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-414-2730
Practice Address - Fax:360-414-2739
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant