Healthcare Provider Details

I. General information

NPI: 1124082292
Provider Name (Legal Business Name): BLAIR R JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W ROWLAND ST
COVINA CA
91723-2943
US

IV. Provider business mailing address

420 W ROWLAND ST
COVINA CA
91723-2943
US

V. Phone/Fax

Practice location:
  • Phone: 626-331-6411
  • Fax: 626-251-1560
Mailing address:
  • Phone: 626-331-6411
  • Fax: 626-251-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11436
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA11436
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA11436
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: