Basic Information
| Provider Information | |||||||||
| NPI: | 1316051964 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1585 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORT POLK | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714595102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375313942 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1585 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORT POLK | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714595102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375313942 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 10/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | A10309 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.