Basic Information
| Provider Information | |||||||||
| NPI: | 1831798321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TRENTON | ||||||||
| MiddleName: | RYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 KOONTZ AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | CLENDENIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250459581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045487272 | ||||||||
| FaxNumber: | 3045427149 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 KOONTZ AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | CLENDENIN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250459581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045487272 | ||||||||
| FaxNumber: | 3045427149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2020 | ||||||||
| LastUpdateDate: | 02/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2508 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.