Provider Demographics
NPI:1578850210
Name:JOHNSON, NICHOLAS BRADFORD
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BRADFORD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
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 277381
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7381
Mailing Address - Country:US
Mailing Address - Phone:208-529-2230
Mailing Address - Fax:208-453-6142
Practice Address - Street 1:3200 CHANNING WAY STE 206
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-529-2230
Practice Address - Fax:208-453-6142
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-14721208200000X, 2086S0122X
GA83999208200000X
IN01076429A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILAM3870816-J1938OtherDEA NUMBER