Basic Information
| Provider Information | |||||||||
| NPI: | 1902025653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | TOVERA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 511 EBENEZER CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305494525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737912983 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 743 SPRING ST NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702199000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2007 | ||||||||
| LastUpdateDate: | 01/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036117169 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 01063115A | IN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 76417 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.