Provider Demographics
NPI:1609849835
Name:JOHNSTON, JERRY LYNN (PA-C)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3865 TIMBERSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9023
Mailing Address - Country:US
Mailing Address - Phone:910-454-8686
Mailing Address - Fax:
Practice Address - Street 1:WOMACK ARMY MEDICAL CENTER
Practice Address - Street 2:MCXC-COD, CREDENTIALS OFFICE, ATTN: SHEILA BLACKWELL
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-0001
Practice Address - Country:US
Practice Address - Phone:910-907-8922
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC104108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical