Basic Information
| Provider Information | |||||||||
| NPI: | 1841373958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEVRIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 WILLIAM PENN PLZ | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | 9193131276 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 E MCCLANAHAN ST | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275652919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196908588 | ||||||||
| FaxNumber: | 9193131276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/07/2014 | ||||||||
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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 | 106H00000X | 5931994-3902 | UT | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 363A00000X | 0010-03936 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.