Healthcare Provider Details

I. General information

NPI: 1962619932
Provider Name (Legal Business Name): DAVID SHANE JOHNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376A SIMPSON HIGHWAY 149
MAGEE MS
39111-3409
US

IV. Provider business mailing address

PO BOX 769
MAGEE MS
39111-0769
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-1475
  • Fax: 601-849-1549
Mailing address:
  • Phone: 601-849-1475
  • Fax: 601-849-1549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA024
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: