1902829583 NPI number — KEITH ALLAN JOHNSON PA-C

Table of content: KEITH ALLAN JOHNSON PA-C (NPI 1902829583)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902829583 NPI number — KEITH ALLAN JOHNSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
KEITH
Provider Middle Name:
ALLAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902829583
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 HOSPITAL DR
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
LEWISBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17837-9350
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-522-4110
Provider Business Mailing Address Fax Number:
570-768-3911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7055 WESTBRANCH HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17837-6808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-524-4141
Provider Business Practice Location Address Fax Number:
570-524-5218
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  MA003170L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: MA003170L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50012614 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P00214218 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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