Basic Information
| Provider Information | |||||||||
| NPI: | 1669588315 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | SHAE | ||||||||
| MiddleName: | HAL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836421026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083025100 | ||||||||
| FaxNumber: | 2083025155 | ||||||||
| Practice Location | |||||||||
| Address1: | 6533 EMERALD STREET | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837048737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083025100 | ||||||||
| FaxNumber: | 2083025155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5960250-1204 | UT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO27594 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | O-0870 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.