Healthcare Provider Details

I. General information

NPI: 1407338627
Provider Name (Legal Business Name): RANDALL JOHNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

601 JOHN ST
KALAMAZOO MI
49007-5341
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-7654
  • Fax:
Mailing address:
  • Phone: 269-341-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008783
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: