Individual
GLEN F JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
524 BEAUMONT RD, FAYETTEVILLE, NC 28304-4443
(800) 476-8646
Mailing address
PO BOX 1070, CHARLOTTE, NC 28201-1070
(800) 476-8646
(919) 382-3210
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
00010366
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00390009
RAILROAD MEDICARE
NC
Enumeration date
06/09/2005
Last updated
02/13/2008
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