Basic Information
| Provider Information | |||||||||
| NPI: | 1902829583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224110 | ||||||||
| FaxNumber: | 5707683911 | ||||||||
| Practice Location | |||||||||
| Address1: | 7055 WESTBRANCH HWY | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178376808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705244141 | ||||||||
| FaxNumber: | 5705245218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA003170L | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | MA003170L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50012614 | 01 | PA | CAPITAL BLUE CROSS | OTHER | P00214218 | 01 | PA | RAILROAD MEDICARE | OTHER |