Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | G62052 | CA |
NPI | 1073671921 |
---|---|
Provider Name | Mr. Randy Phillip Johnson |
First Address | Santa Maria, CA 93455-1302 |
Second Address | Santa Maria, CA 93455-1302 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2006 |
Last Update Date | 16/09/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A93127 | (02) |