Provider Demographics
NPI:1649894676
Name:JOHNSON, BRANDON JAMES (PA-C)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CENTRAL ST STE 880
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-1780
Mailing Address - Country:US
Mailing Address - Phone:847-570-2570
Mailing Address - Fax:847-570-2073
Practice Address - Street 1:240 E HURON ST STE 1-200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2909
Practice Address - Country:US
Practice Address - Phone:312-503-1851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085009350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program