Provider Demographics
NPI:1619687191
Name:JOHNSTON, KEATON JAMES
Entity Type:Individual
Prefix:
First Name:KEATON
Middle Name:JAMES
Last Name:JOHNSTON
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 1:8864 SW MARSEILLES DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-9039
Mailing Address - Country:US
Mailing Address - Phone:208-380-2566
Mailing Address - Fax:
Practice Address - Street 1:8864 SW MARSEILLES DR
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9039
Practice Address - Country:US
Practice Address - Phone:208-380-2566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-25
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program