Healthcare Provider Details

I. General information

NPI: 1114940087
Provider Name (Legal Business Name): CHARLES M JOHNSON JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3824 NE EVANGELINE TRWY
CARENCRO LA
70520-5966
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 337-565-2675
  • Fax: 337-565-2676
Mailing address:
  • Phone: 337-565-2675
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberA30094
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.A10372
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: