Healthcare Provider Details

I. General information

NPI: 1790189629
Provider Name (Legal Business Name): SHAWN JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3108 E LABURNUM AVE
RICHMOND VA
23223-1221
US

IV. Provider business mailing address

3108 E LABURNUM AVE
RICHMOND VA
23223-1221
US

V. Phone/Fax

Practice location:
  • Phone: 804-437-0237
  • Fax: 804-344-3344
Mailing address:
  • Phone: 804-437-0237
  • Fax: 804-344-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: