Provider Demographics
NPI:1629701198
Name:JOHNSON, NATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
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 1:223860 ORCHID LN
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-6629
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9240
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-02
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty