Basic Information
| Provider Information | |||||||||
| NPI: | 1306021753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | CRAIG | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10026 OLD OCEAN CITY BLVD | ||||||||
| Address2: | BUILDING ONE | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106410430 | ||||||||
| FaxNumber: | 4106413871 | ||||||||
| Practice Location | |||||||||
| Address1: | 10344 OLD OCEAN CITY BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106410430 | ||||||||
| FaxNumber: | 4106413871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2008 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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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 | 363AM0700X | C0001907 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.