Healthcare Provider Details

I. General information

NPI: 1922735901
Provider Name (Legal Business Name): MATTHEW RYAN JOHNSON ARNP, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2022
Last Update Date: 09/04/2022
Certification Date: 09/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 ROS CIR
REPUBLIC WA
99166-5002
US

IV. Provider business mailing address

53A PETES RETREAT RD
REPUBLIC WA
99166-9541
US

V. Phone/Fax

Practice location:
  • Phone: 509-775-3153
  • Fax: 509-775-8929
Mailing address:
  • Phone: 425-268-3587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61351549
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60972676
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: