Provider Demographics
NPI:1386383982
Name:JOHNSON, BRYCE (DC)
Entity type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 BRYANTWOOD DR APT 208
Mailing Address - Street 2:
Mailing Address - City:MAPLE PLAIN
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 DIVISION ST E
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1525
Practice Address - Country:US
Practice Address - Phone:763-682-1471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6858111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor