Healthcare Provider Details

I. General information

NPI: 1013571439
Provider Name (Legal Business Name): JASON JOHNSTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2019
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 CALDWELL BLVD
NAMPA ID
83651-1505
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-6567
  • Fax: 208-466-7922
Mailing address:
  • Phone: 208-955-6500
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-15508
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: