Individual
SHAD CARL JOHNSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1151 HOSPITAL WAY BLDG A, POCATELLO, ID 83201-2763
(208) 232-6616
(208) 232-6618
Mailing address
1151 HOSPITAL WAY BLDG A, P.O. BOX 4788, POCATELLO, ID 83201-2763
(208) 232-6616
(208) 232-6618
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA-629
ID
Other
Enumeration date
09/26/2006
Last updated
07/08/2007
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