Provider Demographics
NPI:1982074696
Name:JOHANSEN, BRETT (PA-C)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:JOHANSEN
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 1:1210 NW 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2202
Mailing Address - Country:US
Mailing Address - Phone:208-452-9881
Mailing Address - Fax:
Practice Address - Street 1:1210 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2202
Practice Address - Country:US
Practice Address - Phone:208-452-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1308363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical