Provider Demographics
NPI:1699510420
Name:JOHNSTON, RYAN D
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:D
Last Name:JOHNSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BANCROFT
Mailing Address - State:MI
Mailing Address - Zip Code:48414-9705
Mailing Address - Country:US
Mailing Address - Phone:810-730-1771
Mailing Address - Fax:
Practice Address - Street 1:1201 S STATE ST
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2714
Practice Address - Country:US
Practice Address - Phone:231-591-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351016925390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program