Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 209009443 | IL |
N | 207P00000X | Emergency Physician | A151173 | IA |
Y | 363LP2300X | Nurse Practitioner - Primary Care | 209009443 | IL |
NPI | 1043585573 |
---|---|
Provider Name | Brian D Johnson |
First Address | Dixon, IL 61021-1568 |
Second Address | Dixon, IL 61021-1568 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/03/2012 |
Last Update Date | 20/10/2018 |