Healthcare Provider Details

I. General information

NPI: 1780652974
Provider Name (Legal Business Name): THOMAS W JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NOKOMIS AVE S SUITE 102 & 203
VENICE FL
34285-3209
US

IV. Provider business mailing address

600 NOKOMIS AVE S SUITE 102 & 203
VENICE FL
34285-3209
US

V. Phone/Fax

Practice location:
  • Phone: 941-486-6979
  • Fax:
Mailing address:
  • Phone: 941-486-6979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number544
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9107926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: