Healthcare Provider Details

I. General information

NPI: 1891067070
Provider Name (Legal Business Name): JOHN PAUL JOHNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

463 BMH PHYSICIANS OFFICE BLDG
MARYVILLE TN
37804-5807
US

IV. Provider business mailing address

103 W BROADWAY AVE
MARYVILLE TN
37801-4703
US

V. Phone/Fax

Practice location:
  • Phone: 865-980-5100
  • Fax: 865-980-5105
Mailing address:
  • Phone: 865-273-1752
  • Fax: 865-273-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2094
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: