Provider Demographics
NPI:1821516345
Name:JOHNSON, BENJAMIN DOUGLAS (PA-C, RT (R))
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DOUGLAS
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C, RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 11TH AVE NE STE 200
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1650 COWLES ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5907
Practice Address - Country:US
Practice Address - Phone:907-458-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1382102085R0202X, 2085R0203X, 243U00000X
AK1760938021207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology