Provider Demographics
NPI:1902190051
Name:JOHANSON, RUSSELL A (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
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 718
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-0718
Mailing Address - Country:US
Mailing Address - Phone:907-746-7511
Mailing Address - Fax:907-746-7533
Practice Address - Street 1:2500 S WOODWORTH LOOP
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8984
Practice Address - Country:US
Practice Address - Phone:907-861-6000
Practice Address - Fax:907-861-6000
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDS7975207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine