Healthcare Provider Details

I. General information

NPI: 1356303358
Provider Name (Legal Business Name): GILBERT H JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 LAKE RD
ALTOONA WI
54720-1849
US

IV. Provider business mailing address

1304 LAKE RD
ALTOONA WI
54720-1849
US

V. Phone/Fax

Practice location:
  • Phone: 715-832-0992
  • Fax:
Mailing address:
  • Phone: 715-832-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number218-023
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: