Healthcare Provider Details

I. General information

NPI: 1922495035
Provider Name (Legal Business Name): PATRICK B JOHANSING D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NW 11TH ST STE E15
HERMISTON OR
97838-8602
US

IV. Provider business mailing address

600 NW 11TH ST STE E15
HERMISTON OR
97838-8602
US

V. Phone/Fax

Practice location:
  • Phone: 541-567-6434
  • Fax: 541-429-6613
Mailing address:
  • Phone: 541-567-6434
  • Fax: 541-429-6613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60709245
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberOL60568301
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO198260
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: