MEDICARE: RUSSELL P 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	208VP0000X	Pain Medicine Physician	MA003569L	PA
2	363AM0700X	Medical Physician Assistant	MA003569L	PA
3	363AM0700X	Medical Physician Assistant	PA1753	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1336749811	OTHER	NV	GROUP NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497712483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL P JOHNSON PA-C

Provider Business Mailing Address
First Line	:	7021 SPRING MOUNTAIN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3818
Country	:	US
Telephone Number	:	702-803-2222
Fax Number	:	702-829-7269

Provider Business Practice Location Address
First Line	:	7021 SPRING MOUNTAIN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-3818
Country	:	US
Telephone Number	:	702-803-2222
Fax Number	:	702-829-7269

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

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	11/27/2020

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