Provider Demographics
NPI:1225380629
Name:JOHNSON, PATRICK ALAN (RD LD)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:ALAN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 YAUGER WAY SW
Mailing Address - Street 2:F-202
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8908
Mailing Address - Country:US
Mailing Address - Phone:419-610-1820
Mailing Address - Fax:
Practice Address - Street 1:1115 W BAY DR NW
Practice Address - Street 2:SUITE 202
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4658
Practice Address - Country:US
Practice Address - Phone:360-570-8010
Practice Address - Fax:360-570-8009
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60312524133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
DI60312524OtherWASHINGTON DIETITIAN LICENSURE