Healthcare Provider Details

I. General information

NPI: 1346220670
Provider Name (Legal Business Name): BRYAN N JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W FAIRVIEW ST
COLFAX WA
99111-9552
US

IV. Provider business mailing address

1210 W FAIRVIEW ST
COLFAX WA
99111-9552
US

V. Phone/Fax

Practice location:
  • Phone: 509-397-4717
  • Fax:
Mailing address:
  • Phone: 509-397-4717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00026794
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: