Healthcare Provider Details

I. General information

NPI: 1225380629
Provider Name (Legal Business Name): PATRICK ALAN JOHNSON RD, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N CENTER AVE
GAYLORD MI
49735-1592
US

IV. Provider business mailing address

825 N CENTER AVE
GAYLORD MI
49735-1592
US

V. Phone/Fax

Practice location:
  • Phone: 989-731-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012837
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDI60312524
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: