Provider Demographics
NPI:1467433706
Name:PERRY, JOHNATHAN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:R
Last Name:PERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6703 W RIO GRANDE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-2623
Mailing Address - Country:US
Mailing Address - Phone:509-460-5588
Mailing Address - Fax:509-783-5438
Practice Address - Street 1:6703 W RIO GRANDE AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2623
Practice Address - Country:US
Practice Address - Phone:509-460-5588
Practice Address - Fax:509-783-5438
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034127207XX0005X, 207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
246488OtherLABOR & INDUSTRIES
WAP00815483OtherRR MEDICARE
WA8403784Medicaid
WAP00815483OtherRR MEDICARE
WA8403784Medicaid
WA1098748Medicaid
AB11148Medicare PIN
WA8403784Medicaid