Provider Demographics
NPI:1639373152
Name:JOHNSON, SHANA (MD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
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 1:344 CLEVELAND AVE SE STE C
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-3342
Mailing Address - Country:US
Mailing Address - Phone:360-464-7940
Mailing Address - Fax:360-362-8749
Practice Address - Street 1:344 CLEVELAND AVE SE STE C
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-3342
Practice Address - Country:US
Practice Address - Phone:360-464-7940
Practice Address - Fax:360-362-8749
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD 60001063208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8521783Medicaid
BP1-0022479OtherINSTITUTIONAL PERMIT
WA0241237OtherL&I
WAMD 60001063OtherMEDICAL LICENSE
WA8521783Medicaid