Basic Information
| Provider Information | |||||||||
| NPI: | 1801931001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | YOUNG | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 22ND STREET SOUTH SUITE 1000 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352468007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057155943 | ||||||||
| FaxNumber: | 2057155932 | ||||||||
| Practice Location | |||||||||
| Address1: | 831 1ST ST N | ||||||||
| Address2: | |||||||||
| City: | ALABASTER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350078944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056201085 | ||||||||
| FaxNumber: | 2056201091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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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 | PA.509 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 51005353 | 01 | AL | BLUE CROSS | OTHER | 009942984 | 05 | AL | MEDICAID |