MEDICARE: GLEN F JOHNSON PA

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	00010366	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00390009	OTHER	NC	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1619971561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN F JOHNSON PA

Provider Business Mailing Address
First Line	:	PO BOX 1070
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28201-1070
Country	:	US
Telephone Number	:	800-476-8646
Fax Number	:	919-382-3210

Provider Business Practice Location Address
First Line	:	524 BEAUMONT RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4443
Country	:	US
Telephone Number	:	800-476-8646
Fax Number	:

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	02/13/2008

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