Healthcare Provider Details

I. General information

NPI: 1689732901
Provider Name (Legal Business Name): ABRAHAM D JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6926 NE FOURTH PLAIN BLVD
VANCOUVER WA
98661
US

IV. Provider business mailing address

PO BOX 1337
VANCOUVER WA
98666-1337
US

V. Phone/Fax

Practice location:
  • Phone: 360-993-3000
  • Fax: 360-993-3047
Mailing address:
  • Phone: 360-993-3000
  • Fax: 360-993-3047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNC10070587
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: