Provider Demographics
NPI:1659660439
Name:JOHNSON, MEGAN WHITNEY (PA)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:WHITNEY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11006 SPENCER HWY
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571
Mailing Address - Country:US
Mailing Address - Phone:281-470-2100
Mailing Address - Fax:281-867-8219
Practice Address - Street 1:11006 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571
Practice Address - Country:US
Practice Address - Phone:281-470-2100
Practice Address - Fax:281-867-8219
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07200363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1659660439OtherTRICARE
TXPA07200OtherLISCENSE
TX313985901Medicaid
TX889N41OtherBCBS
TXPA07200OtherLISCENSE