Healthcare Provider Details

I. General information

NPI: 1164179214
Provider Name (Legal Business Name): RYAN THOMAS JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 12/04/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 WARING RD
OCEANSIDE CA
92056-4405
US

IV. Provider business mailing address

3905 WARING RD
OCEANSIDE CA
92056-4405
US

V. Phone/Fax

Practice location:
  • Phone: 760-724-9000
  • Fax: 760-724-3686
Mailing address:
  • Phone: 760-724-9000
  • Fax: 760-724-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: