Healthcare Provider Details

I. General information

NPI: 1174692198
Provider Name (Legal Business Name): JOHNNY MICHAEL JONES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SEAFARERS WAY STE 201 B
ANACORTES WA
98221-2257
US

IV. Provider business mailing address

PO BOX 1048
ANACORTES WA
98221-1048
US

V. Phone/Fax

Practice location:
  • Phone: 360-588-1460
  • Fax: 360-588-1473
Mailing address:
  • Phone: 360-588-1460
  • Fax: 360-588-1473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004470
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPA10004470
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: