Provider Demographics
NPI:1760672612
Name:JOHANSON, RYAN E (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:E
Last Name:JOHANSON
Suffix:
Gender:M
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:PO BOX 2483
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2483
Mailing Address - Country:US
Mailing Address - Phone:541-602-6211
Mailing Address - Fax:
Practice Address - Street 1:1128 NE 2ND ST STE 104
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6293
Practice Address - Country:US
Practice Address - Phone:541-602-6211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD27209207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8487746Medicaid
OR274438Medicaid
ORP00784755OtherRR MEDICARE
WA8487746Medicaid