Basic Information
| Provider Information | |||||||||
| NPI: | 1093054033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | BENJAMIN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52948 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379502948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653065675 | ||||||||
| FaxNumber: | 8655847712 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 PARK WEST BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656905263 | ||||||||
| FaxNumber: | 8655883740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2013 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2291 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA2291 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | Q000510 | 05 | TN | MEDICAID |