Basic Information
| Provider Information | |||||||||
| NPI: | 1174551295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7210 40TH ST W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535640170 | ||||||||
| FaxNumber: | 2532074240 | ||||||||
| Practice Location | |||||||||
| Address1: | 7210 40TH ST W | ||||||||
| Address2: | STE 100 | ||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535640170 | ||||||||
| FaxNumber: | 2532074240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00039365 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 160004 | 01 | WA | STATE L&I | OTHER | 8311359 | 05 | WA | MEDICAID | 8937028 | 01 | WA | STATE CRIME VICTIMS | OTHER | 080188803 | 01 | WA | RAILROAD | OTHER | 160005 | 01 | WA | STATE L&I | OTHER |