Healthcare Provider Details

I. General information

NPI: 1649894676
Provider Name (Legal Business Name): BRANDON JAMES JOHNSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 01/23/2023
Certification Date: 01/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 E HURON ST STE 1-200
CHICAGO IL
60611-2909
US

IV. Provider business mailing address

1000 CENTRAL ST STE 880
EVANSTON IL
60201-1780
US

V. Phone/Fax

Practice location:
  • Phone: 312-503-1851
  • Fax:
Mailing address:
  • Phone: 847-570-2570
  • Fax: 847-570-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085009350
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: