Provider Demographics
NPI:1316438807
Name:JOHNSON, BRYAN REUBEN (PA-C)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:REUBEN
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8350 BARTON AVE NW
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2749
Mailing Address - Country:US
Mailing Address - Phone:763-587-8662
Mailing Address - Fax:
Practice Address - Street 1:1700 E. CESAR CHAVEZ AVE
Practice Address - Street 2:SUITE 2500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-9003
Practice Address - Country:US
Practice Address - Phone:323-328-8059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant