=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710721832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAUL L JOHNSON PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2024
-----------------------------------------------------
Last Update Date | 06/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 MARYWOOD DR
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27520-9066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-791-7209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 MARYWOOD DR
-----------------------------------------------------
City | CLAYTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27520-9066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-791-7209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZS0410X
-----------------------------------------------------
Taxonomy Name | Surgical Technologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------