Basic Information
| Provider Information | |||||||||
| NPI: | 1770527665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20355 E APPALOOSA DR | ||||||||
| Address2: | |||||||||
| City: | QUEEN CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852427136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026189273 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6644 E BAYWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852061747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809812000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3325 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.