Basic Information
| Provider Information | |||||||||
| NPI: | 1306803911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8035 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672080035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166899135 | ||||||||
| FaxNumber: | 3166899667 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 N AMIDON AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672032125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3168329024 | ||||||||
| FaxNumber: | 3168329478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 04/29/2014 | ||||||||
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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 | 04-24151 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100158730 B | 05 | KS | MEDICAID | 003719198 | 01 | KS | MEDICARE | OTHER |