Healthcare Provider Details

I. General information

NPI: 1033971759
Provider Name (Legal Business Name): CARNELL D JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 OLD BRICK RD
GLEN ALLEN VA
23060-5837
US

IV. Provider business mailing address

2151 OLD BRICK RD
GLEN ALLEN VA
23060-5837
US

V. Phone/Fax

Practice location:
  • Phone: 804-727-6853
  • Fax:
Mailing address:
  • Phone: 804-727-6853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: