MEDICARE: SHANA JOHNSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	208100000X	Physical Medicine & Rehabilitation Physician	MD 60001063	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	BP1-0022479	OTHER		INSTITUTIONAL PERMIT
3	0241237	OTHER	WA	L&I
4	MD 60001063	OTHER	WA	MEDICAL LICENSE

General Provider Information

NPI Number	:	1639373152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANA JOHNSON MD

Provider Business Mailing Address
First Line	:	344 CLEVELAND AVE SE STE C
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98501-3342
Country	:	US
Telephone Number	:	360-464-7940
Fax Number	:	360-362-8749

Provider Business Practice Location Address
First Line	:	344 CLEVELAND AVE SE STE C
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98501-3342
Country	:	US
Telephone Number	:	360-464-7940
Fax Number	:	360-362-8749

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	08/11/2020

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Directions to “ SHANA JOHNSON MD” Practice Location

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