Provider Demographics
NPI:1083785760
Name:JOHNSON, WAYNE CLAIR
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:CLAIR
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 N GOVERNMENT WAY
Mailing Address - Street 2:SUITE #7
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815
Mailing Address - Country:US
Mailing Address - Phone:208-762-0797
Mailing Address - Fax:208-762-0791
Practice Address - Street 1:3115 N GOVT WAY
Practice Address - Street 2:SUITE #7
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-3790
Practice Address - Country:US
Practice Address - Phone:208-762-0797
Practice Address - Fax:208-762-0791
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8053443Medicaid
ID5127610001Medicare NSC