1962746172 NPI number — DEREK A JOHNSON PA-C

Table of content: DEREK A JOHNSON PA-C (NPI 1962746172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962746172 NPI number — DEREK A JOHNSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
DEREK
Provider Middle Name:
A
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:
1962746172
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 NW 13TH ST FL 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33486-2305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-955-5790
Provider Business Mailing Address Fax Number:
561-955-5791

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 NW 13TH ST FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOCA RATON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33486-2305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-955-5790
Provider Business Practice Location Address Fax Number:
561-955-5791
Provider Enumeration Date:
11/15/2012

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:  PA9106805 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3011968 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 398531 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: P01707166 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1039541 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 4179920 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 974430 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: IFS7Z . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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