1063689172 NPI number — MR. RYAN JOHNSON PA

Table of content: MR. RYAN JOHNSON PA (NPI 1063689172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063689172 NPI number — MR. RYAN JOHNSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
RYAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1063689172
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8501 FM 407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOUBLE OAK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75077-3031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-966-1980
Provider Business Mailing Address Fax Number:
972-691-4937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
391 HIGHWAY 377 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARGYLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76226-5113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-784-7301
Provider Business Practice Location Address Fax Number:
469-519-1461
Provider Enumeration Date:
05/08/2008

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: 363A00000X , with the licence number:  1078006 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA08258 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 293067600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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