Healthcare Provider Details

I. General information

NPI: 1164345534
Provider Name (Legal Business Name): EZEQUIEL ANTHONY JOHNSON P-PRC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7091 W EMERALD ST
BOISE ID
83704-8618
US

IV. Provider business mailing address

7091 W EMERALD ST
BOISE ID
83704-8618
US

V. Phone/Fax

Practice location:
  • Phone: 208-880-0863
  • Fax:
Mailing address:
  • Phone: 208-880-0863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: