Basic Information
| Provider Information | |||||||||
| NPI: | 1598951113 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PAAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3155 N POINT PKWY | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT, BUILDING F, SUITE 100 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 JOHNSON FERRY ROAD | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706459181 | ||||||||
| FaxNumber: | 7706458455 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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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 | 367H00000X | 5147 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 846135851A | 05 | GA | MEDICAID | 846135851C | 05 | GA | MEDICAID | 846135851B | 05 | GA | MEDICAID |