Basic Information
| Provider Information | |||||||||
| NPI: | 1336124098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | TIMOTHY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 MAR WALT DR | ||||||||
| Address2: | FAMILY MEDICINE DEPARTMENT | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508636600 | ||||||||
| FaxNumber: | 8508620977 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 MAR WALT DR | ||||||||
| Address2: | FAMILY MEDICINE DEPARTMENT | ||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325476707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508636600 | ||||||||
| FaxNumber: | 8508620977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9101157 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 290698800 | 05 | FL | MEDICAID | Y0CH5 | 01 | FL | BCBSFL | OTHER |