Basic Information
Provider Information | |||||||||
NPI: | 1609093277 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JOHNSON | ||||||||
FirstName: | DERRICK | ||||||||
MiddleName: | BERNARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2925 PALO VERDE AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908151552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624292473 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2925 PALO VERDE AVE | ||||||||
Address2: |   | ||||||||
City: | LONG BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 908151552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5624292473 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/18/2007 | ||||||||
LastUpdateDate: | 11/09/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA15689 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.