Provider Demographics
NPI:1922628700
Name:ST JOHN, BRIAN PHILLIP
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PHILLIP
Last Name:ST JOHN
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:P.O. BOX 1679 #4068
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95812
Mailing Address - Country:US
Mailing Address - Phone:424-285-3890
Mailing Address - Fax:
Practice Address - Street 1:1500 11TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95814-5701
Practice Address - Country:US
Practice Address - Phone:424-285-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDHS-6189Z251G00000X, 253Z00000X, 372600000X, 3747A0650X, 374U00000X, 385H00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No251G00000XAgenciesHospice Care, Community Based
No253Z00000XAgenciesIn Home Supportive Care
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care