Healthcare Provider Details

I. General information

NPI: 1710578117
Provider Name (Legal Business Name): PARKER BRANDT JOHNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2021
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN STE 111
BLOOMINGTON IL
61704-8112
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax: 309-663-4529
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008197
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: