Healthcare Provider Details

I. General information

NPI: 1275512543
Provider Name (Legal Business Name): SHANE REED JOHNSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 12/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E HAWAII AVE
NAMPA ID
83686-6011
US

IV. Provider business mailing address

217 W GEORGIA AVE SUITE 115
NAMPA ID
83686-6811
US

V. Phone/Fax

Practice location:
  • Phone: 208-463-3234
  • Fax: 208-463-3044
Mailing address:
  • Phone: 208-463-3234
  • Fax: 208-463-3044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA293
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA293
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: