Individual
GARY LYNN JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
610 CHESTNUT ST, SOUTH CHARLESTON, WV 25309-1251
(304) 766-7515
(304) 766-7566
Mailing address
107 ROCKY STEP RD, SCOTT DEPOT, WV 25560-9631
(304) 412-4243
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
01092
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01092
LICENSE
WV
01
—
1071247
WV DWC
WV
Enumeration date
03/02/2006
Last updated
12/17/2007
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