Healthcare Provider Details

I. General information

NPI: 1730715640
Provider Name (Legal Business Name): IAN JOHNSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 MDG/SGHC, UNIT 5071 APO AP 96328-5071
APO AP
96328-5071
US

IV. Provider business mailing address

374 MDG/SGHC, UNIT 5071 APO AP 96328-5071
APO AP
96328-5071
US

V. Phone/Fax

Practice location:
  • Phone: 315-225-7508
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOP61190273
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: