Healthcare Provider Details

I. General information

NPI: 1235102500
Provider Name (Legal Business Name): DANNY JOHNSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7061 GRAND MONTECITO PKWY
LAS VEGAS NV
89149-0287
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 702-243-8500
  • Fax: 702-363-8753
Mailing address:
  • Phone: 702-877-5153
  • Fax: 702-363-8753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA665
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: