Provider Demographics
NPI:1518986413
Name:JOHNSON, KRISTEN RANDI (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RANDI
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-4201
Mailing Address - Country:US
Mailing Address - Phone:206-329-1760
Mailing Address - Fax:
Practice Address - Street 1:11011 MERIDIAN AVE N
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8967
Practice Address - Country:US
Practice Address - Phone:206-525-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8457558Medicaid
WAI58363Medicare UPIN
WA8863909Medicare PIN