Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | APRN11001964 | FL |
NPI | 1003376328 |
---|---|
Provider Name | Mr. Colton Kyle Johnston |
First Address | Panama City Beach, FL 32407-4286 |
Second Address | Panama City, FL 32405-4582 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2019 |
Last Update Date | 27/01/2022 |