Provider Demographics
NPI:1609969674
Name:JOHNSON, ROBERT EDWARD (PA-C)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2724 N HALIFAX AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32118-3142
Mailing Address - Country:US
Mailing Address - Phone:321-297-7115
Mailing Address - Fax:
Practice Address - Street 1:800 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3256
Practice Address - Country:US
Practice Address - Phone:386-261-8608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102838363A00000X
NC0010-02065363AM0700X
GA005331363AM0700X
FLPA 9102838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP1025Medicare PIN
S77124Medicare UPIN