MEDICARE: LUKE CONNOR JOHNSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA15621	TX

General Provider Information

NPI Number	:	1063009983
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUKE CONNOR JOHNSON PA-C

Provider Business Mailing Address
First Line	:	2701 S CONGRESS AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-6413
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2701 S CONGRESS AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-6413
Country	:	US
Telephone Number	:	512-759-8385
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2020
Last Update Date	:	04/08/2022

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