Healthcare Provider Details

I. General information

NPI: 1205147469
Provider Name (Legal Business Name): NICHOLAS JAMES JOHNSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 N 115TH ST
SEATTLE WA
98133-8401
US

IV. Provider business mailing address

1550 N 115TH ST
SEATTLE WA
98133-8401
US

V. Phone/Fax

Practice location:
  • Phone: 415-793-1716
  • Fax:
Mailing address:
  • Phone: 415-793-1716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT198202
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT198202
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD 60450666
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: