Provider Demographics
NPI:1033345715
Name:JOHNSON, WAYNE (LMP)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 BRISTOL CT SW
Mailing Address - Street 2:SUITE A-103
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-6003
Mailing Address - Country:US
Mailing Address - Phone:360-350-0015
Mailing Address - Fax:360-350-0019
Practice Address - Street 1:2401 BRISTOL CT SW
Practice Address - Street 2:SUITE A-103
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-6003
Practice Address - Country:US
Practice Address - Phone:360-878-7506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024292174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist