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NPI Code Detail

MEDICARE: MR. MARK SAMUEL JOHNSON PA-C MT ASCP

MEDICARE: MR. MARK SAMUEL JOHNSON PA-C MT ASCP
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
1363A00000XPhysician Assistant2010013488MO

General Provider Information

NPI Number : 1568453132
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MARK SAMUEL JOHNSON PA-C MT ASCP
Provider Business Mailing Address
First Line : 200 CORPORATE BLVD
Second Line :
City : LAFAYETTE
State : LA
Zip : 70508-3870
Country : US
Telephone Number : 800-893-9698
Fax Number :
Provider Business Practice Location Address
First Line : 300 1ST CAPITOL DR
Second Line :
City : SAINT CHARLES
State : MO
Zip : 63301-2844
Country : US
Telephone Number : 636-947-5000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/02/2005
Last Update Date : 03/13/2020

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