Provider Demographics
NPI:1285863043
Name:JOHNSON, WAYNE DENNIS JR (IDMT)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:DENNIS
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 S CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:FAIRCHILD AFB
Mailing Address - State:WA
Mailing Address - Zip Code:99011-8548
Mailing Address - Country:US
Mailing Address - Phone:509-247-5414
Mailing Address - Fax:
Practice Address - Street 1:2504 S CHICAGO ST
Practice Address - Street 2:
Practice Address - City:FAIRCHILD AFB
Practice Address - State:WA
Practice Address - Zip Code:99011-8548
Practice Address - Country:US
Practice Address - Phone:509-247-5414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians