Basic Information
| Provider Information | |||||||||
| NPI: | 1588627376 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHANSON | ||||||||
| FirstName: | PAXTON | ||||||||
| MiddleName: | MCKEOWN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 PRINCETON AVE SW | ||||||||
| Address2: | 200A | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057862776 | ||||||||
| FaxNumber: | 2057866227 | ||||||||
| Practice Location | |||||||||
| Address1: | 833 PRINCETON AVE SW | ||||||||
| Address2: | 200A | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057862776 | ||||||||
| FaxNumber: | 2057866227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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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 | 363AS0400X | PA9102616 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA-469 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 291696700 | 05 | FL | MEDICAID |