Basic Information
| Provider Information | |||||||||
| NPI: | 1669607800 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33269 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850673269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024064786 | ||||||||
| FaxNumber: | 9166364358 | ||||||||
| Practice Location | |||||||||
| Address1: | 21300 N JOHN WAYNE PKWY STE 115 | ||||||||
| Address2: | |||||||||
| City: | MARICOPA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851398978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204263424 | ||||||||
| FaxNumber: | 5205689560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 10/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA2009-0007 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 8117 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.