Provider Demographics
NPI:1962638452
Name:PAYNE, JOHNNY PHILLIP (FNP DNP)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:PHILLIP
Last Name:PAYNE
Suffix:
Gender:M
Credentials:FNP DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 SISKIYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8125
Mailing Address - Country:US
Mailing Address - Phone:541-304-8008
Mailing Address - Fax:541-612-3557
Practice Address - Street 1:2655 SISKIYOU BLVD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8125
Practice Address - Country:US
Practice Address - Phone:541-304-8008
Practice Address - Fax:541-612-3557
Is Sole Proprietor?:No
Enumeration Date:2009-06-10
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201250098NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201250098NPOtherOREGON LICENSE