Provider Demographics
NPI:1508872763
Name:JOHNSON, BRYAN WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:WAYNE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-302-9342
Mailing Address - Fax:
Practice Address - Street 1:1072 N LIBERTY ST STE 300
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8708
Practice Address - Country:US
Practice Address - Phone:208-302-2300
Practice Address - Fax:208-302-2355
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2055363A00000X
GA1071708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant