Provider Demographics
NPI:1164021713
Name:JOHNSON, CLAY
Entity type:Individual
Prefix:
First Name:CLAY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RIVERHILL APT B
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:PA
Mailing Address - Zip Code:18938-1262
Mailing Address - Country:US
Mailing Address - Phone:716-307-1563
Mailing Address - Fax:
Practice Address - Street 1:8100 WESCOTT DR
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-4671
Practice Address - Country:US
Practice Address - Phone:908-264-5993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061958363A00000X
NJ25MP00676700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant