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 1:308 PRALEY ST NW
Mailing Address - Street 2:
Mailing Address - City:VALDESE
Mailing Address - State:NC
Mailing Address - Zip Code:28690-2328
Mailing Address - Country:US
Mailing Address - Phone:321-297-7115
Mailing Address - Fax:
Practice Address - Street 1:2280 US HIGHWAY 70 SE
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-5164
Practice Address - Country:US
Practice Address - Phone:828-267-1201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9102838363A00000X
FLPA 9102838363A00000X
GA005331363AM0700X
NC0010-02065363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP1025Medicare PIN
S77124Medicare UPIN