Provider Demographics
NPI:1174692198
Name:JONES, JOHNNY MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:MICHAEL
Last Name:JONES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1048
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-1048
Mailing Address - Country:US
Mailing Address - Phone:360-588-1460
Mailing Address - Fax:360-588-1473
Practice Address - Street 1:715 SEAFARERS WAY
Practice Address - Street 2:STE 201 B
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2257
Practice Address - Country:US
Practice Address - Phone:360-588-1460
Practice Address - Fax:360-588-1473
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004470174400000X
WA10004470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA277551OtherSTATE OF WA L & I
WA1174822159Medicaid
WA1174692198Medicaid
WAS51660Medicare UPIN
WA1174692198Medicaid