Provider Demographics
NPI:1982289864
Name:JOHANSON, BROCK ROBERT
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:ROBERT
Last Name:JOHANSON
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 1:6575 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:STANSBURY PARK
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9063
Mailing Address - Country:US
Mailing Address - Phone:208-540-1691
Mailing Address - Fax:
Practice Address - Street 1:6575 HARVEST LN
Practice Address - Street 2:
Practice Address - City:STANSBURY PARK
Practice Address - State:UT
Practice Address - Zip Code:84074-9063
Practice Address - Country:US
Practice Address - Phone:208-540-1691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program