Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | M10563 | ID |
N | 207QS0010X | Family Doctor - Sports Medicine | M-10563 | ID |
NPI | 1164402681 |
---|---|
Provider Name | Dr. John A. Johnson |
First Address | Boise, ID 83712 |
Second Address | Nampa, ID 83686 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2006 |
Last Update Date | 18/09/2012 |