Healthcare Provider Details

I. General information

NPI: 1326248022
Provider Name (Legal Business Name): DAVID LYLE JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5169 S COTTONWOOD ST SUITE 510
MURRAY UT
84107-6767
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3513
  • Fax:
Mailing address:
  • Phone: 801-507-3513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5314229-8002
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5314229-8002
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5314229-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: