Provider Demographics
NPI:1881444677
Name:JOHNSON, WADE RUSSELL (DO)
Entity type:Individual
Prefix:DR
First Name:WADE
Middle Name:RUSSELL
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15097 S 54TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:KIEFER
Mailing Address - State:OK
Mailing Address - Zip Code:74041
Mailing Address - Country:US
Mailing Address - Phone:360-259-9779
Mailing Address - Fax:
Practice Address - Street 1:2345 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-2705
Practice Address - Country:US
Practice Address - Phone:918-582-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program