Healthcare Provider Details

I. General information

NPI: 1710949789
Provider Name (Legal Business Name): LANE W JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 E PATHFINDERS DR
BELFAIR WA
98528-9157
US

IV. Provider business mailing address

2351 9TH ST S
ARLINGTON VA
22204-2359
US

V. Phone/Fax

Practice location:
  • Phone: 360-275-4927
  • Fax:
Mailing address:
  • Phone: 703-695-6545
  • Fax: 703-693-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA34580
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: