Provider Demographics
NPI:1992430201
Name:JOHNSON, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:JOHNSON
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 1:8383 NE SANDY BLVD STE 440
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4986
Mailing Address - Country:US
Mailing Address - Phone:971-373-4041
Mailing Address - Fax:971-373-5285
Practice Address - Street 1:8383 NE SANDY BLVD STE 110B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4967
Practice Address - Country:US
Practice Address - Phone:971-373-4041
Practice Address - Fax:971-373-5285
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist