Provider Demographics
NPI:1619772506
Name:JOHNSON, CHAD ELIJAH
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ELIJAH
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 HIHN RD
Mailing Address - Street 2:
Mailing Address - City:BEN LOMOND
Mailing Address - State:CA
Mailing Address - Zip Code:95005-9615
Mailing Address - Country:US
Mailing Address - Phone:559-284-5244
Mailing Address - Fax:559-284-5244
Practice Address - Street 1:1555 SOQUEL DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1705
Practice Address - Country:US
Practice Address - Phone:831-462-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-15
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95169322163WC0200X
CA5184364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine