Provider Demographics
NPI:1730197252
Name:JOHNSON, TROY (PAC)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 SIDEWINDER DR
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-7492
Mailing Address - Country:US
Mailing Address - Phone:435-655-6600
Mailing Address - Fax:
Practice Address - Street 1:1820 SIDEWINDER DR
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-7492
Practice Address - Country:US
Practice Address - Phone:435-655-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT379295-1206363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107033706101OtherSELECTHEALTH
UT80922OtherPUBLIC EMPLOYEES HEALTH P
UT841433992TRYOtherEDUCATORS MUTUAL
UT231831OtherALTIUS HEALTH PLANS
UT005581607Medicare PIN
UT107033706101OtherSELECTHEALTH