Healthcare Provider Details

I. General information

NPI: 1407426034
Provider Name (Legal Business Name): ANDREW PHILLIP JOHNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 SKYLARK CT
CHESAPEAKE VA
23321-1245
US

IV. Provider business mailing address

3241 WESTERN BRANCH BLVD STE A
CHESAPEAKE VA
23321-5260
US

V. Phone/Fax

Practice location:
  • Phone: 757-567-2129
  • Fax:
Mailing address:
  • Phone: 757-686-3508
  • Fax: 757-686-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110-008093
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: