Provider Demographics
NPI:1679738272
Name:JOHNSON, MICHAEL FREDERICK (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:FREDERICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1802 NORTH JACKSON STREET
Mailing Address - Street 2:SUITE 8
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388
Mailing Address - Country:US
Mailing Address - Phone:931-455-4520
Mailing Address - Fax:931-455-4633
Practice Address - Street 1:1802 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:TULLAHOMA
Practice Address - State:TN
Practice Address - Zip Code:37388-8218
Practice Address - Country:US
Practice Address - Phone:931-455-4529
Practice Address - Fax:931-455-4633
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1564363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I977681Medicare PIN