Healthcare Provider Details

I. General information

NPI: 1528169612
Provider Name (Legal Business Name): JAY HUNTER JOHNSTON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 FRIST BLVD STE 204
FORT PIERCE FL
34950-4838
US

IV. Provider business mailing address

1285 36TH ST SUITE 100
VERO BEACH FL
32960-4885
US

V. Phone/Fax

Practice location:
  • Phone: 772-462-3939
  • Fax: 772-462-3938
Mailing address:
  • Phone: 772-778-2009
  • Fax: 772-778-2910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103921
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: