Provider Demographics
NPI:1861592131
Name:JOHNSON, MARK P (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:P
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
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Other - Credentials:
Mailing Address - Street 1:PO BOX 63362
Mailing Address - Street 2:DUMC BOX 3624, 047 BAKER HOUSE, TRENT DRIVE
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-620-4918
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:TISCH BRAIN TUMOR CENTER AT DUKE
Practice Address - Street 2:DUMC BOX 3624, 047 BAKER HOUSE, TRENT DRIVE
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-684-5301
Practice Address - Fax:919-684-6674
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-04-06
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Provider Licenses
StateLicense IDTaxonomies
NC102978363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC9660AMedicare PIN
NC2747608BMedicare PIN